Here comes AdvanceMed

Saturday, April 30, 2005

Editor's Note: This column is the first in a series co-written by all four DMERC medical directors. Look for this column in a new home next month on our editorial pages.


Q. I recently received a development letter from AdvanceMed requesting documentation on a claim I submitted to the DMERC. Who is AdvanceMed, and why are they asking for this information?
A. AdvanceMed is a Comprehensive Error Rate Test (CERT) contractor. CERT is a program used by CMS to monitor the Claims Payment Error Rate. The goal of the Comprehensive Error Rate Testing (CERT) program is to ensure that Medicare claims are paid correctly and accurately. AdvanceMed determines the error rate by selecting a sample of claims from each DMERC, developing them and making an independent adjudication determination. The result is compared to the DMERC determination for the same claim. Differences in outcome create the error rate.
The DMERCs are responsible for monitoring the results o of the CERT program. CMS and the DMERCs then use this information to help focus our Medical Review activities with the goal of keeping the error rate as low as possible. One of the major contributing factors to the error rate is the non-response of suppliers to the CERT requests for documentation.
If you receive a letter identifying a claim that has been selected for review by the CERT contractor, we strongly encourage you to respond to the request for documentation promptly and completely. Follow the directions in the CERT request letter and send the documentation as the letter directs.
In early April 2005, the task of requesting and receiving medical records for the CERT program will be transitioned from AdvanceMed to a second CERT contractor -- called the CERT Documentation Contractor. For several months, it is possible that suppliers may get request letters from either one or both of the CERT contractors. You should be careful to follow the directions on each CERT letter you receive to ensure that the medical records are faxed or mailed to the correct location.
If you do not submit the requested medical documentation, you may be subject to an overpayment request for the claim(s) that were selected for review. If you have questions or comments, please contact the CERT Operations Center at 804-264-1778.