NCI, Reston, Virginia, announced that it was awarded an $87 million firm-fixed-price contract with the Centers for Medicare & Medicaid Services (CMS) to continue support of CMS’ Comprehensive Error Rate Testing (CERT) program by NCI and AdvanceMed, its wholly-owned subsidiary. The expanded scope of work includes request and receipt of medical documentation for Medicare claims billed and call center support. The award consists of a one-year base period and four one-year option periods.
CMS developed the CERT program to calculate the Medicare fee-for-service (FFS) program’s improper payment rate using a sample of claims from the Medicare claims universe to determine whether the claims have been paid properly based on Medicare coverage, coding, and billing rules. NCI will utilize the medical review tracking, reviewing, and reporting system it built for CMS, CERT360, which integrates and controls all aspects of the CERT program’s medical review activity. The system’s three-tier design incorporates best practices compiled from managing and completing more than 1.5 million Medicare medical review audits for CMS.
NCI will work with billing and ordering providers to receive and process medical records for conducting medical reviews. The company will also provide customer service support to the Medicare Administrative Contractors (MACs) and providers that have claims sampled for review. It will conduct medical reviews on claims sampled for CERT and other CMS accuracy reviews, communicate results, and maintain various websites for internal and external stakeholders. NCI’s expanded role incorporates the request and receipt of medical records associated with these claims and provides a “one-stop shop” for MACs, providers, and others for CMS continuity of services, according to the announcement.
NCI also will provide the data from the review of these claims to CMS for the agency’s use in submitting the National Medicare FFS program’s improper payment rate to the U.S. Congress and to publicly report the findings and actions CMS is taking to reduce improper payments.
