Medicare's Program Integrity Initiatives

Published 03/07/2018

For many years, the Centers for Medicare & Medicaid (CMS) has funded programs to reduce claims payment errors (either paying too much, paying too little, or payments being made when none should be). Some of these programs are handled through systematic checks that look for anomalies and mismatched services, and some are handled through clinical reviews of specific claims. 

The program integrity initiatives pertaining to Railroad Medicare include:

Medically Unlikely Edits (MUEs) – These are systematic checks that look for claims that exceed the maximum number of services expected to be reported, in most cases, for a single patient by the same provider on a single day.

National Correct Coding Initiative (NCCI) Edits – These are also systematic checks, and they look for combinations of codes that should not be reported together in all or most situations. Either we would not expect both services to occur in one treatment, or Medicare does not reimburse both services when performed together. This could be two codes that represent different methods of performing the same service, such as a laparoscopic gallbladder removal and an open incision gallbladder removal.  It could also be two codes that are components of each other, such as a rhythm electrocardiograph (ECG) and a cardiovascular stress test, which by definition includes an ECG.

Medical Review Program – This initiative involves complex reviews by Medicare (including Railroad Medicare) in which documentation is requested, and then the reviews determine if the claim was correctly billed and properly documented, and that the services meet Medicare coverage criteria. 

Comprehensive Error Rate Testing (CERT) Program – This initiative involves complex reviews in the same manner as the Medical Review program. External entities include the CERT Review Contractor, the CERT Documentation Contractor, and the CERT Statistical Contractor, and they work together to review a random sample of claims and determine an error rate for local Medicare, as well as Railroad Medicare. 

They do this by:

  • Requesting medical records from providers who submitted claims
  • Reviewing claims and medical records for compliance with Medicare coverage, coding and billing rules

The CERT program calculates an improper payment rate, and it also develops an improper payment rate by claim type, to measure Medicare (and Railroad Medicare’s) performance processing claims correctly. 
Working together, these initiatives reduce the number of claims that are underpaid, overpaid, or should never have been paid. 

If you have any questions about your Railroad Medicare coverage, please call our Beneficiary Contact Center at 800-833-4455, Monday through Friday, from 8:30 a.m. to 7 p.m. ET. We encourage you to sign up for email updates. To do so, click 'Listservs' on the top of this webpage to start the process. 

We also encourage you to visit our Facebook page at

Was this article helpful?