For revenue cycle leaders, maintaining compliance while minimizing financial risk is an ongoing challenge. As healthcare entities continue to see increasing risk from changes to government policies, shifting patient demographics, and shrinking margins, risk management will become an increasingly essential focus for survival. One of the most effective tools for achieving risk management goals is examining the application of Comprehensive Error Rate Testing (CERT) and how it impacts organizations that deal with Medicare payments.
Whether your organization manages billing internally or partners with medical billing outsourcing companies in the USA, leveraging CERT findings can refine compliance strategies, reduce audit exposure, and strengthen revenue integrity.
Understanding the CERT Program
The CERT program, administered by the Centers for Medicare & Medicaid Services (CMS), was designed to measure improper payment rates in Medicare fee-for-service claims under the Payment Integrity Information Act of 2019 (PIIA) [1]. The program ensures Medicare payments adhere to coverage, coding, and billing regulations through a rigorous review process.
Each year, the CERT program examines approximately 37,500 randomly selected claims processed by Medicare Administrative Contractors (MACs). An independent medical review contractor evaluates these claims to determine if they meet Medicare’s documentation, medical necessity, and coding requirements. Claims that fail compliance standards are classified as either total or partial improper payments. It’s important to note that an improper payment does not imply fraud – it simply means the claim did not fully align with Medicare guidelines. For medical billing services in the USA, this distinction is critical when addressing compliance gaps and refining processes.
CERT Supports Compliance for Healthcare Providers
Revenue cycle professionals can use CERT data as a strategic compliance tool, identifying systemic issues before they escalate into costly denials or audits. The program’s annual reports highlight key error trends, offering actionable insights for improving billing accuracy [2].
One of the most significant findings from CERT reports is the breakdown of improper payment root causes. Insufficient documentation accounts for 63.6% of errors, often due to missing or incomplete medical records. Medical necessity errors (13.8%) and incorrect coding (10.5%) follow closely behind, with upcoding and mismatched documentation showing up as recurring issues.
Certain specialties and services are particularly high-risk. For example, Durable Medical Equipment (DME) claims have an improper payment rate of 21.41%, making them a frequent audit target. Similarly, Evaluation & Management (E/M) services face persistent coding challenges, particularly with upcoded office visits. By analyzing these trends, providers and medical billing companies in the USA can implement targeted training and documentation improvements to mitigate risk.
The Department of Health and Human Services publishes reports every November to cover improper payment rates in the Agency Financial Report. CMS then publishes a more highly detailed, improper payment rate information report. This comes in the form of the annual Medicare Fee-for-Service (FFS) Improper Payments Report and Appendices. They are accessible here by year with the most recent report published November 11, 2024 [3].
Reducing Financial Risk Through CERT Insights
Revenue cycle leaders can use CERT data as an early warning system to proactively address vulnerabilities [4]. One of the most effective strategies is benchmarking internal denial rates against national CERT averages. For example, the overall Medicare FFS improper payment rate in 2024 was 7.66%. If an organization’s internal error rates exceed this benchmark, leadership should consider investing in process improvements. If process improvements require too many resources and too much time, leadership should consider working with medical billing outsourcing companies in the USA.
Strengthening documentation practices is another way to address issues and reduce risks. Since insufficient documentation is the leading cause of improper payments, revenue cycle leaders should enforce strict documentation protocols or look for medical billing companies in the USA who can provide them with this type of support.
High-risk specialties, such as orthopedics and DME billing, require extra scrutiny. Regular coder training on the latest E/M coding updates can also prevent upcoding errors. Additionally, CERT data helps predict which services may face Targeted Probe & Educate (TPE) audits, allowing organizations to prepare in advance. If audited, companies can reference CERT’s 95% confidence intervals to challenge overstated error rates, protecting revenue from unjust recoupments. If risk has been a persistent issue at your organization, outsourcing can be a smart decision to get the most out of CERT data and see faster benefits in your revenue cycle processes.
A Proactive Approach to Compliance
Information from the CERT program is more than a compliance requirement – it’s a strategic asset for providers and those who outsource medical billing. By analyzing error trends, benchmarking performance, and addressing high-risk areas, organizations can reduce denials, avoid audits, and safeguard revenue. By integrating CERT insights into compliance strategies, revenue cycle leaders can stay ahead of Medicare’s evolving requirements, ensuring long-term stability and success.
If your team needs expert guidance in leveraging CERT data or optimizing revenue cycle processes, 3Gen Consulting specializes in helping providers achieve compliance and efficiency. Contact us today to learn how we can support your organization in minimizing risk and maximizing financial performance.
References
[1] CMS, “What’s the Comprehensive Error Rate Testing (CERT) Program?,” 26 January 2022. Available: https://www.cms.gov/outreach-and-educationmedicare-learning-network-mlnmlnproductsfast-facts/whats-comprehensive-error-rate-testing-cert-program.
[2] F. Cohen, “How CERT Empowers You to Improve Billing and Coding Compliance,” RACmonitor, 7 February 2024. Available: https://racmonitor.medlearn.com/how-cert-empowers-you-to-improve-billing-and-coding-compliance/.
[3] CMS, “CERT Reports,” 11 November 2024. Available: https://www.cms.gov/data-research/monitoring-programs/improper-payment-measurement-programs/comprehensive-error-rate-testing-cert/cert-reports.
[4] AAPC, “Assess CERT Findings to Identify Your Risk Areas,” 13 April 2023. Available: https://www.aapc.com/codes/coding-newsletters/my-urology-coding-alert/compliance-assess-cert-findings-to-identify-your-risk-areas-174933-article?srsltid=AfmBOoqT7z5Oqs4i8R1SyaeHpYgSljgAjM-taoKRllNwFKx2gv3SfyEW.
