Billing errors could result in a request for repayment
Recently, the AAOS received a report of an orthopaedic provider who had three claims for joint replacement surgery flagged for CERT (Comprehensive Error Rate Testing) violations. The payer, Highmark Medicare, demanded retroactive payment from both the hospital and orthopaedic surgeon for the orthopaedic care of the patients involved. Although there are anecdotal reports of similar claims—all from the same payer—this case marks the first time an orthopaedic surgeon was asked to provide retroactive payment under the CERT process.
What is CERT?
The CERT program was established by the Centers for Medicare & Medicaid Services (CMS) to calculate national paid claims error rates for the Medicare program. Until recently, CERT reviews were focused exclusively on hospital billing. In the second half of 2010, however, CERT violations were expanded to include physician claims associated with procedures performed in hospitals.
The CERT review conducted by Highmark Medicare relied on standards known as InterQual Criteria. Developed by a private healthcare company, InterQual Criteria Products are described as “the best possible support for appropriateness of care and related clinical decision-making.” The developer suggests that these standards “foster the practice of evidence-based medicine and protect patient safety while avoiding medically unnecessary care.”
How is liability determined?
Under the CERT process, claims are randomly selected from the involved healthcare providers and evaluated for compliance with Medicare coverage, coding, and billing rules. If any claims are determined to be incorrect, providers are sent overpayment notices or adjustments are made for claims that were overpaid or underpaid.
The CERT program is not considered a measure of fraud; rather, it looks for instances of miscoding or misbilling. Therefore, errors result in fiscal penalties instead of criminal penalties. If a CERT review flags a provider, other authorities can pursue further investigations, but the CERT process itself only involves fiscal restitution.
The AAOS response
It is unclear if other orthopaedic providers have had similar CERT-related audits or if the Highmark Medicare case is an isolated incident involving a handful of practices. To study this process and how it might impact the delivery of musculoskeletal care of the patients treated by our fellowship, the AAOS Health Care Systems Committee has initiated a CERT Issues Workgroup.
AAOS fellows who have a request for a CERT or other Medicare audit are encouraged to communicate with their specialty societies or directly with the Health Care Systems Committee via staff liaison Matthew Twetten, so we may have a better understanding of the CERT process and the impact on patient care.
Matthew Twetten, MA, is the AAOS senior health policy analyst.