The U.S. Government Accountability Office (GAO) has found that the Centers for Medicare & Medicaid Services (CMS) does not have reliable data or sufficient oversight to measure and prevent duplication of postpayment claims reviews.
CMS should provide additional oversight and guidance regarding data, duplicative reviews and contractor correspondence to improve effectiveness and efficiency of postpayment claims reviews, the GAO recommends in its report.
The GAO reviewed four types of contractors that examine providers’ documentation to determine whether Medicare’s payment was proper.
These contractors include Medicare Administrative Contractors (MAC), which process and pay claims; Zone Program Integrity Contractors (ZPIC), which investigate potential fraud; Recovery Auditors (RA), which identify on a postpayment basis improper payments not previously reviewed by other contractors; and the Comprehensive Error Rate Testing (CERT) contractor, which reviews claims used to annually estimate Medicare’s improper payment rate.
“Because different types of contractors conduct similar claims reviews, CMS guidance, oversight and coordination of them is essential to maintaining an appropriate balance between detecting improper payments effectively and efficiently and avoiding unnecessary administrative burdens,” the GAO writes. “Further actions by CMS could help improve the efficiency and effectiveness of its contractors’ efforts.”
A lack of reliable data and oversight, inconsistent contractor guidance and requirements, and noncompliance with CMS requirements are among the chief concerns the GAO notes in its report.
In order to improve Medicare postpayment claims review efforts and simplify compliance for providers, CMS should monitor the Recovery Audit Data Warehouse, develop complete guidance to define contractors’ responsibilities, clarify the current requirements and assess regularly whether contractors are complying, the report states.
Read the full report here.
Written by Emily Study