RE: Medicare CERT Audits

[Guest guest]

& All

My comments are based on experience and fact, there is no speculation

involved. The final three comments at the close represent my opinion on

protecting your practice.

CERT:

First of all ensure that it is a CERT audit, and not an audit from one of

the ZPICs or Program Safeguard Contractors (or subcontrators), or a request

for medical record review by your MAC on behalf of the program safeguard

contractor. The Comprehensive Error Rate Testing Program (CERT) requests

medical records to review and validate the CMS contractor error rate. The

statement of work for the CERT has to do with developing the CMS contractor

error rate, not provider audits and recoupment (that is generally what the

RAC Contractors do)

Any subsequent denials resulting from a CERT review and findings that claims

was paid in error would come from your Medicare contractor, not the CERT

contractor. Most of the CMS contractors publish their CERT error rates by

category, and within the category provide examples. Correspondence from

CMS contractor will all have the CMS logo on the letterhead, so it may be

confusing to determine who the letter is from. Providers will know it is a

CERT letter by comparing letter received to these samples on the CERT

website:

Initial Part B request:

https://www.certprovider.com/certproviderportal/pages/sampleletters/PartB%20

Initial%20EN.pdf

Second Request:

https://www.certprovider.com/certproviderportal/pages/sampleletters/PartB%20

Second%20EN.pdf

Third Request:

https://www.certprovider.com/certproviderportal/pages/sampleletters/PartB%20

Third%20EN.pdf

Other Activity:

Right now there is a substantial amount of activity going in in which

physical therapy clinics, CORFs, and rehab agencies are being subject to

various CMS program integrity initiatives including:

.. Medicare enrollment re-validations (which has nothing to do with

survey and certification, but a CMS mandate to revalidate Medicare suppliers

and providers every 5 years, or sooner if warranted).

.. Unannounced site visits for physical therapists in private

practice (new enrollments and change of information) to validate the

existence of the individual and the verification of the address of practice

and operating hours

.. Unannounced site visits for PT/OT practices enrolling as a DME

supplier in which not only verification of clinic, hours of operation etc,

but a review medical records (involving DME), as well as a review of other

elements required from DME suppliers including complaint logs etc. This

unannounced site visit will also be triggered by a change of information

form (855).

.. Unannounced site visits in areas of high fraud and abuse by the

ZPIC and Program Safeguard contractors.

.. High volumes of claim requests to small providers with payments

suspended by claims review is underway (allowed under the Patient Protection

and Affordable Care Act).

For providers in Medicare Strike Force cities the activity targeting therapy

clinics is extremely high, and CORFs have been under the microscope,

particularly in Florida where program integrity reviews have resulted in the

closure of over 60+ CORFs South Florida alone in the past year. South

Florida providers are currently reporting aggressive activity and payment

suspension under the new investigative authority.

If a provider has received a " threatening letter " I will be glad to provide

a conduit to the proper authority if you contact me directly.

My opinion as a compliance professional:

It is important for therapy providers to be aware of key protections when

Medicare comes knocking at the door:

1. What agency is involved? Keeping in mind that the ZPIC and the PSC

statement of work is fraud detection and investigation. This is different

than an investigator for your MAC verifying a PT enrollment and that the

place of practice

2. If someone comes to your clinic for an unannounced visit note the

who, what, when, where and why. Be aware of situations in which you need to

call your compliance officer or your compliance attorney so that

attorney-client privilege can be invoked if an investigation is in the

works.

3. Have a compliance plan in place, based upon a valid risk assessment

and for small practices utilize the OIG Guidance for Physicians and Small

Practices.

New Phone:

J. Beckley, MS, MBA, CHC

Beckley & Associates LLC

<http://nancybeckley.com> http://nancybeckley.com

<http://rehabcomplianceblog.com> http://rehabcomplianceblog.com

Direct:

From: PTManager [mailto:PTManager ] On Behalf

Of Kovacek

Sent: Wednesday, July 20, 2011 12:12 PM

To: PTManager

Subject: Medicare CERT Audits

PTManagers

Does anyone have any recent experience they could share on the Medicare CERT

Audit process?

One of our PTManager members wants to stay anon but just got what they

describe as a " threatening " letter for a CERT Audit

Please respond to entire list, not me individually

Thanks in advance

Kovacek, PT, DPT, MSA

PKovacek@... <mailto:PKovacek%40PTManager.com>

Cell

Personal Fax

www.PTManager.com