Established by Centers for Medicare and Medicaid Services (CMS) to monitor and report the accuracy of Medicare fee-for-service (FFS) payments. The national error rate is calculated using a combination of data from the CERT contractor and HPMP with each component representing about 60% and 40% of the total Medicare FFS dollars paid. The CERT program measures the error rate for claims submitted to carriers, durable medical equipment regional carriers (DMERCs), and fiscal intermediaries (FIs). The HPMP measures the error rate for the quality improvement organizations (QIOs). Beginning in 2003, CMS elected to calculate a provider compliance error rate in addition to the paid claims error rate. The provider compliance error rate measures how well providers prepare Medicare FFS claims for submission. CMS calculates the Medicare FFS error rate and estimate of improper claim payments using a methodology the Office of the Inspector General approved. The CERT methodology includes randomly selecting a sample of approximately 120,000 submitted claims, requesting medical records from providers who submitted the claims, and reviewing the claims and medical records for compliance with Medicare coverage, coding, and billing rules.

Payment to a facility for the health services given to treat an inpatient.

State-licensed physicians with privileges to admit patients for treatment and medical services. May sometimes be referred to as organized staff or medical staff .

In 1913, the year of its founding, the American College of Surgeons appointed Codman to chair a committee on hospital standardization and to establish the College’s standardization program. This endeavor represents an integral part of the College’s history because it evolved into the Joint Commission on Accreditation of Hospitals in 1951 and the Joint Commission on Accreditation of Healthcare Organizations in 1987.

Doctor of medicine or osteopathy, salaried or unsalaried, under contract or arrangement who renders that service and treatment in a hospital setting rather than in an office environment.

Printed document sent by a hospital to a Medicare beneficiary when the hospital determines the medical service the patient is receiving or is about to receive is not covered due to either medical necessity, not being delivered in the appropriate setting, or being considered custodial. An HINN may be given before admission, at admission, or any time during the inpatient stay.