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RAC vs. CERT Audits: Do You Know the Difference?

Andrea Kraynak, for HealthLeaders Media, November 11, 2009

The Comprehensive Error Rate Testing (CERT) Hospital Payment Monitoring Program is one of the ways CMS is trying to improve the quality and accuracy of Medicare claim submission and payment of those claims. Is that so different from what the RAC program is designed to do?

While the end-goal may be the same, the methodology is very different. Stacey Levitt, RN, MSN, CPC, director of patient care management at Lenox Hill Hospital in New York City, outlines some of the important differences between the two types of Medicare audits:

  • Who is being audited. RACs look for errors made by providers, but the CERT is looking for errors in payments made by carriers. Hospitals and other providers are affected because when the CERT looks into a claim, the provider must submit the medical records, and if the CERT uncovers an error, the CERT will take back money from the hospital. But the CERT is really looking for errors made by fiscal intermediaries, Medicare administrative contractors or other carriers when paying providers' Medicare claims.

  • Education. "CERTs want to make sure everything is on the up and up for the claims," Levitt explains. When the patterns of incorrectly paid claims appear on its radar, the CERT steps in and educates providers. RACs don't provide such education.

  • Payment. RACs are paid through contingency fees. The more under- or over-payments they uncover, the more money they receive. The payment for CERTs is different; they receive a set amount outlined in their contract, regardless of the percentage of payment errors they find.

  • Size of the program. The RAC program has gotten much more attention than the CERT program, but it may be because the RAC program has the potential to be a much bigger headache for providers. The CERTs examine random claim samples—often only looking at a very small percentage of a carrier's claims. So the CERT would likely request only a small number of medical records from providers paid by that carrier. And the potential takeback, if any, would likely be smaller as well.

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