The Department of Health and Human Services, Centers for Medicare and Medicaid Services has a continuing requirement for Comprehensive Error Rate Testing Review Contractor services.

The Payment Integrity Information Act of 2019 (PIIA) requires the heads of federal agencies, including the Department of Health and Human Services (HHS), to annually

Identify programs that may be susceptible to significant improper   payments,
Estimate the amount of improper payments in those programs,
Submit the estimates to Congress, and
Report publicly the estimate and actions the Agency is taking to reduce improper payments.

An improper payment is defined as any payment that should not have been made or that was made in an incorrect amount (including overpayments and underpayments) under statutory, contractual, administrative, or other legally applicable requirements. In addition, improper payments include those to an ineligible recipient, payments for ineligible goods or services, duplicate payments, payments for goods or services not received (except for such payments where authorized by law), and any payments that do not account for credit for applicable discounts.

The Centers for Medicare & Medicaid Services (CMS) developed the Comprehensive Error Rate Testing (CERT) program to calculate the Medicare Fee-for-Service (FFS) program improper payment rate. The CERT program considers any claim that was paid or denied when it should have been denied or paid at another amount (including both overpayments and underpayments) to be an improper payment. To meet this objective, a stratified random sample of Medicare FFS claims is selected for review; supporting documentation is retrieved from the provider or supplier who submitted the claim for payment; and the documentation is reviewed by independent medical reviewers to determine if the claim was paid properly under Medicare coverage, coding, and billing rules. If the documentation does not support that the rules were met, the claim is counted as either a total or partial improper payment. The error is then categorized into one of five major categories: (1) No Documentation, (2) Insufficient Documentation, (3) Medical Necessity, (4) Incorrect Coding, or (5) Other.

The CERT program calculates improper payment rates based on the results of the reviews conducted. These rates include an overall national Medicare FFS improper payment rate and improper payment rates for each claim type [Part A inpatient hospital prospective payment system (PPS); Part A excluding inpatient hospital PPS; Part B; and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)]. The CERT program ensures a statistically valid random sample; therefore, the improper payment rate calculated from this sample is considered to be reflective of all of claims processed by Medicare FFS program during the report period. CMS also uses the CERT program to perform special studies to determine the improper payment rates of particular claim types. Calculations of these rates facilitate CMS’ ability to take appropriate corrective actions to reduce improper payments.

• CMS seeks to acquire a CERT Review Contractor (herein, “Contractor”) to, at a minimum:
  • Select a stratified random selection of claims from the Medicare FFS claims universe
  • Request medical records from the billing and ordering providers to support the claims billed
  • Receive and process medical records for purposes of conducting medical review ( MR)
  • Provide customer service support to the Medicare Administrative Contractors (MACs) and providers who have claims selected for review
  • Conduct MR on claims selected for CERT and other accuracy reviews, as specified by CMS
  • Communicate MR results to the MACs, providers, and other stakeholders
  • Collect and transmit data to the CERT Statistical Contractor (CERT SC) for purposes of calculating improper payment rates
  • Maintain various websites for internal and external stakeholders
  • Establish mechanisms to manage, monitor and mitigate unexpected fluctuations in the Contractor’s workload
  • Perform additional tasks to support the mandate of the CERT program, as directed by  CMS and this Statement of Work (SOW)