Program Comparison: Medical Review, CERT and Recovery Audit
The table below summarizes the similarities and differences between CGS's Medical Review Program, the Comprehensive Error Rate Testing (CERT) Program, and the Recovery Audit Program
Medical Review | CERT | Recovery Audit | |
---|---|---|---|
Providers Impacted | All Medicare Fee-for-service (FFS) providers | All Medicare FFS providers | All Medicare FFS providers |
Medicare Contractor | Medicare Administrative Contractors (MACs) (i.e. CGS) | CERT Review Contractor CERT Documentation Contractor | Medicare Recovery Auditors |
Claims Impacted/ Number of Claims Selected | Targeted claim review; numbers vary | Random sample; limited numbers | Widespread or targeted claim review; numbers vary |
Prepayment Edit | Yes | No | No* * Some prepayment review in limited demonstration states only. |
Postpayment Review | Yes, possible | Yes | No – if clear payment error Yes – if likely payment error |
Provider response/action required | Submit medical documentation within 30 days of additional development request (ADR) | Submit medical documentation within 75 days from receipt of CERT letter | Submit medical documentation within 45 days of date of letter (or request an extension) |
Right to Appeal | Yes | Yes | Yes |
Additional Resources:
- CGS Medical Review
- CGS "Comprehensive Error Rate Testing (CERT) Program" webpage
- Recovery Audit Program
Reviewed: 11.30.21