CERT Audits and Error Rate Findings: The Provider Response

The Centers for Medicare & Medicaid Services (CMS) measures Medicare fee-for-service payment accuracy through the CERT program, and a practice does not need to have done anything wrong to be pulled into it. CERT selects claims at random, without any suspicion of fraud, and reviews them against Medicare coverage, coding, and payment rules. For the reporting period ending June 30, 2024, CMS reported a national improper payment rate of 6.55 percent, representing $28.83 billion. Once your practice's claim is flagged, a documentation deadline, a possible repayment demand, and an appeal clock all start running from the date on the notice.

How CERT Selects and Reviews Claims

CERT draws a stratified random sample of approximately 37,500 claims each reporting period from those submitted to Part A/B Medicare Administrative Contractors (MACs) and durable medical equipment MACs. An independent medical review contractor checks each sampled claim against Medicare coverage, coding, and payment rules, including any applicable local coverage determination for the billed service. The sample is not targeted at a provider with a history of problems. CMS is explicit that the resulting error rate is not a fraud rate; it is a measurement of payments that did not meet Medicare's coverage, coding, or documentation requirements.

The 45-Day Documentation Deadline

A CERT documentation request gives a practice 45 calendar days from the date of the request to submit medical records supporting the sampled claim. The CERT Documentation Center will grant extensions, but only for providers who contact it directly with a specific reason more time is needed. Silence is the costliest response: if the records do not arrive, or the record set does not support what was billed, CMS counts the claim as a total or partial improper payment, the same outcome as failing the review on the merits. Our related guide on Responding to a Medicare Additional Documentation Request (ADR) walks through that response process in more detail.

From Error Finding to Repayment Demand

Once the review contractor completes its determination, CERT notifies the Medicare Administrative Contractor of every improper payment finding, and the MAC recoups the overpayment or reimburses the underpayment through the ordinary claims-adjustment process. Durable medical equipment claims carried the highest FY2025 improper payment rate among claim types at 24.12 percent, well above the 8.44 percent rate for Part B providers and the 6.67 percent rate for other Part A providers. A pattern of CERT errors also becomes part of the error-rate data that CMS uses to refine its broader payment-accuracy and program integrity models, which is why a CERT finding deserves the same documentation discipline as a targeted audit even though the underlying sample was random.

A CERT audit begins as a random statistical sample. It ends, for the provider whose claim was flagged, as a real repayment demand with a real appeal deadline.

Appealing a CERT-Identified Error

A CERT improper payment finding carries the same appeal rights as any other Medicare claim denial. The first step is redetermination, filed with the Medicare Administrative Contractor within 120 days of the determination. An unfavorable redetermination proceeds to reconsideration before a Qualified Independent Contractor, then to a hearing before an administrative law judge, then to the Medicare Appeals Council, and finally to federal district court. Our related guide, The Medicare Audit Process: Contractors, Stages, and Deadlines, maps each contractor type and its deadlines side by side.

Why Early Legal Counsel Is Critical

It is critical that healthcare providers promptly retain experienced healthcare defense counsel upon receiving a CERT documentation request, audit notice, or other government inquiry. Early legal intervention can protect the provider's rights, ensure appropriate responses to government requests, avoid inadvertent admissions, preserve relevant defenses, and allow counsel to communicate with investigators on the provider's behalf. Delaying legal representation can significantly affect the outcome of a matter and expose the provider to unnecessary risk.

How Health Law Alliance Can Help

Health Law Alliance defends providers through CERT documentation requests, the improper payment determinations that follow, and the Medicare appeal process that comes after. If your practice has received a CERT notice or a repayment demand tied to a CERT finding, contact us for a free, confidential consultation.