Medicare: Types of Audits & Records Requests

When you receive a request for records, please be aware that it can come from many different sources for many possible reasons.  It is important to keep in mind that it does not mean you have done anything wrong - some of these requests are just generated at random. Your request may have come from a CERT (Comprehensive Error Rate Testing) contractor, from an A/B MAC (Medicare Administrative Contractor), a RAC (Recovery Audit Contractor), another type of CMS contractor, or the OIG (Office of the Inspector General). Carefully review the letter you have received noting the specific information requested, the deadline for submission of records and the address where you should submit your information. This information is frequently found IN the letter and is not the same as the address on the letterhead.

If you have received a request for records, it is extremely important to respond in a complete and timely fashion.  

If you receive a denial, after submitting your records, it is important to file an appeal and follow through with the process. 

  • For more information on the Medicare Part B Appeals Process, click here.

Denial from a Medicare Administrative Contractor

ACA encourages all DCs to appeal improperly denied claims. Appealing is not only a service to your patient, who has a right to have their payable covered services reimbursed, but a service to your profession. Medicare Administrative Contractors (MACs) will often perform post-payment or pre-payment reviews.

  • Post-payment review. Post-payment review involves review of a claim after payment has been made. Post-payment review is commonly performed by using Statistically Valid Sampling. Sampling allows an underpayment or overpayment (if one exists) to be estimated without requesting all records on all claims from providers.
  • Pre-payment review. Pre-payment review consists of review of a claim prior to payment. Providers with identified problems submitting correct claims may be placed on pre-payment review, in which a percentage of their claims are subjected to review before payment can be authorized. Once providers have re-established the practice of billing correctly, they are removed from pre-payment review.

Both post-payment and pre-payment reviews may require providers to submit medical records. When medical records are requested, the provider must submit them within the specified timeframe or the claim will be denied.

Request for Records from a CERT

The Comprehensive Error Rate Testing program (CERT), is a Centers for Medicare & Medicaid Services (CMS)-contracted process of determining the accuracy with which Medicare contractors review and process Medicare claims.  The method by which this evaluation is done involves the request and review of medical record documentation.

These reviews are very important, not only for the individual doctor, but most certainly for the chiropractic profession as a whole. Findings of the CERT review, along with the Office of Inspector General (OIG) reviews, will determine our coverage within the Medicare, Medicaid, VA, and DOD. If our documentation is inadequate in showing medical necessity, we may end up completely out of the program(s) or vice versa. Given this information, your full compliance and, even more importantly, your documentation used to show medical necessity, are of utmost importance.

For each request on date(s) of service (DOS), you will want to make sure that you send in the notes for that DOS and all related information - including the most recent exam, full history, treatment plan, and any diagnostic findings. All of these items help a reviewer place the pertinent DOS in a larger context. 

It is important to note that these reviews are random in nature and assist CMS in obtaining an overall view of how various groups are performing including: the carriers, regions of the country, services, professions, etc. CERT reviews are independent of Medicare carriers/MACs. Doctors must respond promptly to CERT requests for records. Your letter will from CERT will indicate the timeframe within which you need to respond. Most often providers have 60 days to respond. For CERT special studies, providers are only given 30 days to respond. If you disagree with your CERT findings, you are given the opportunity to appeal.

2014 Change in CERT Medical Record Request Process

Effective for all initial CERT documentation request letters sent on or after January 1, 2014, providers will now only receive three letters (day 1, day 30, day 45) from the CERT contractor and therefore the response time will be shortened to 60 days (instead of 75). If, after 60 days, the contractor has not received the requested information, the claim will be considered a “no documentation” error. As always, when you receive a request for records from any source, it is important to carefully review the letter noting the specific information requested, the deadline for submission of records, and the address where you should submit your information.

Additional CERT Resources

Request for Records from OIG

The Department of Health and Human Services (HHS), Office of the Inspector General (OIG) is the entity responsible for identifying and reporting inefficiency in Medicare, Medicaid and other related HHS agencies.

We ask that all doctors of chiropractic who receive an OIG record request to please contact ACA for assistance in fully complying with the request.

It is critical that doctors of chiropractic include all necessary information, including the most recent exam and the most recent full history, upon receipt of an OIG record request.  It is also imperative that this be done in a timely fashion (by the date specified by the OIG).  

RAC Audit

Each Recovery Audit Contractor is responsible for identifying overpayment and underpayments in approximately ¼ of the country. Recovery Audit Contractors must receive approval from CMS before investigating different types of claim errors. Review the information below to determine the RAC contractor in your area, the issues approved for RAC reviews and how to respond to a RAC audit. Please note that the appeal process for RAC denials is the same as the appeal process for Carrier/FI/MAC denials.  It is also extremely important to note that, to date, no RACs have specifically requested to review the billing of Chiropractic Manipulative Treatment codes. 

Questions? Contact ACA.