Audits are the new normal
CMS uses Comprehensive Error Rate Testing (CERT) audits to see if MACs are properly paying claims. CERT audits focus on logistical issues, such as whether or not the coding and billing are correct. CERT is looking for errors in payments made by carriers. Providers are affected because the CERT looks into a claim via Medical Records request. If the CERT uncovers an error, the CERT will recoup money from the provider. CERTs receive set amount outlined in their contract, regardless of the amount of payment errors they find.
Recovery Audit Contractors focus on errors created by the providers. The primary purpose of RAC is to detect and correct improper payments. RACs are paid through contingency fees (money they uncover). The contingency fee payment system encourages RACs to find errors.
Zone Program Integrity Contractors (ZPICs) are the most complex audits. ZPICs compare providers billing with similar providers. ZPIC reviews are not random. They are conducted under a presumption of fraud. ZPICs can be initiated by data analysis, frequency, whistleblowers or referred by MACs. Once an error is found they extrapolate the data in order to determine the amount of misappropriated funds.
Blog by Sarah McIntosh, Director of Operations