Are You Driving Up Chiropractic's CERT Rating?

Are You Driving Up Chiropractic's CERT Rating?

Author: Mark Crawford/Wednesday, March 23, 2016/Categories: November 2014

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By Mark Crawford 

EVERYONE HATES PAPERWORK - IT SLOWS US DOWN. It’s tedious. And if you do it yourself, it keeps you from seeing more patients.

However, incomplete claims or inaccurate claims submitted by doctors of chiropractic (DCs) to Medicare and Medicaid are damaging chiropractic’s professional reputation.

The Centers for Medicare and Medicaid Services (CMS) established the Comprehensive Error Rate Testing (CERT) program to determine the percentage of claims paid properly under Medicare coverage, coding and billing rules. This involves requesting and reviewing medical record documentation on an annual basis from different medical professions, including doctors of chiropractic.

Unfortunately for chiropractic services, CERT has revealed consistently high rates of improper payments. According to the CMS website, for fiscal year 2013, the average Medicare fee-for-service program improper payment rate was 10.1 percent, representing $36 billion in improper payments. In contrast, chiropractic’s improper payment rate for 2013 is an overwhelming 51.7 percent — the result of insufficient documentation.

How CERT Works

CERT randomly selects a statistical sample of claims for review to determine whether the claims were paid properly. The CERT program relies on two contractors to accomplish this work: the CERT review contractor and the CERT documentation contractor.

The CERT review contractor is responsible for reviewing the selected claims and associated medical record documentation. The CERT documentation contractor handles requesting and receiving the medical record documentation from providers. The CERT documentation-contractor call center tries to make an initial telephone contact with the provider to explain the program, followed by a faxed or mailed medical record request letter.

These reviews are extremely important for both the individual DC and the chiropractic profession. Conclusions based on the CERT numbers, along with Office of the Inspector General (OIG) reviews, determine chiropractic coverage within the Medicare, Medicaid, VA and DOD. If documentation by DCs is inadequate, it is possible chiropractic will not be covered by these programs. Therefore, it is critical that every DC submit the best documentation possible, especially for demonstrating medical necessity.

CERT Medical Record Request

Selecting chiropractors for review is a random process. If you receive a medical record request, provide all the information requested — including the most recent exam, full history, treatment plan and any diagnostic findings.

“Do not change your notes once you receive this request,” indicates Steven Conway, DC, J.D., vice chair of the ACA Medicare committee and chair of the ACA audit defense task force. “Many DCs want to improve their notes once they receive this request. However, if your documentation is not as complete as you would like, provide a cover letter to assist in the review, but do not make any modifications to your notes.”

The request letter from CERT indicates the time frame within which you need to respond. The only CERT change from 2013 is that the response period has been shortened from 75 days to 60 days.

“If the CERT documentation contractor does not receive the requested documentation within 30 days of the initial letter, it will be followed by a series of letters and phone calls to the provider,” adds Michael Jacklitch, DC, Medicare expert and ACA state delegate from North Dakota. “If no documentation is received by the 60th day, the claim will be considered a no-documentation error.”

Responding to CERT

It is imperative that providers respond to the CERT request promptly. If the requested documentation is not received within the required time period, the CERT documentation contractor will assume that the services on the claim were not rendered. “Failure to produce the documentation will count as an error in the calculation of the CERT program error rate and will result in the computation of an overpayment,” says Dr. Jacklitch. “The Medicare contractor will pursue overpayment recoupment for these undocumented services.”

Why is chiropractic’s error rating so high?

“Overall, we have a large percentage of DCs who simply do not respond,” says Dr. Conway. “One reason could be that the majority of our DCs are practicing in individual offices and do not have a dedicated person to handle regulatory requests or issues such as those found in group practices and hospital settings.”

Another possibility is that DCs do not fully understand the severity of non-response or improper documentation. “They look at the cost factor of time involved to respond and decide it is not worth the effort, or worry about sending in poor records and decide instead to take a chance that nothing will happen,” Dr. Conway adds.

The most damaging thing a DC can do is ignore the request, thinking that simply accepting a denial and subsequent recoupment for the service dates in question will be less costly than taking the time and effort to respond to the request. “Compliance is essential to demonstrate professional application for medical necessity, not only for the individual practitioner, but for the entire profession as well,” says Dr. Jacklitch. “The CERT error rate reflects directly on the chiropractic profession’s demonstration of necessity for inclusion in national healthcare programs.”

Improving Our Reputation

When compared with the CERT error rates of other medical professions, the rates for DCs make it clear that they must do a better job of documentation.

“The basic formats of travel cards need to be abandoned for Medicare documentation, unless the format contains all of the required and specific items outlined in the Medicare beneficiary manual,” says Dr. Conway. “Many of our DCs have a documentation system that contains the basic information for a patient encounter, but lacks specific Medicare required notations, which increases our CERT denial rate. Missing information related to treatment plans is a high factor in our denial rate.”

Documentation requirements are not difficult. They are specifically presented in an outline format in the Medicare benefits policy manual and can also be found on the ACA website. “If all DCs would document according to these very basic standards, we would dramatically decrease our CERT error ratio,” says Dr. Conway. “New electronic health records systems can also help DCs comply with required documentation.”

Responding to a CERT request is the most important thing a DC can do. Send in the requested information and any additional documentation that would assist the reviewer to understand the care provided on that date within the CERT time frame.

Dr. Conway warns that if CERT error rates remain high, more DCs will be audited.

“This was recently demonstrated when several DCs around the United States received a letter from OIG requesting information on a single patient,” he says. “I see this trend of increased audits continuing because OIG has repeatedly reported on our high error rate. This is a very serious issue that we as a profession must handle now, not in the distant future.”

The objective of CERT is to lower the error rate — a goal that DCs should fully embrace.

“A lower error rate gives providers more time to provide efficient and quality care to patients and less time on claim denials and appeals,” adds Dr. Jacklitch. “Professional and timely responses to requested records by CERT contractors, and a willingness to advance our personal and professional documentation standards will have a significant impact on our inclusion in the future national healthcare picture.”

HHS OIG Auditing Chiropractic Records: ACA Offers Member Help

The ACA was recently notified that the Office of the Inspector General (OIG) is conducting a nationwide review of the chiropractic profession. Doctors of chiropractic have received letters requesting records for services provided during calendar year 2013. It is critical that all DCs who receive a letter from the OIG respond with the requested documentation and by the specified deadline[The Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS) is the entity dedicated to identifying and combating fraud, waste and abuse and improving efficiency in Medicare, Medicaid and other HHS programs.]

ACA strongly recommends that doctors of chiropractic who receive an OIG record request consult with their personal attorney and also contact ACA via e-mail at so ACA can provide essential information to help you navigate the OIG request process. 


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