Friday, November 8, 2013

GAO Releases Medicare Program Integrity Report

By Dianne De La Mare

The US Government Accountability Office (GAO) recently released a report, Medicare Program Integrity: Increasing Consistency of Contractor Requirements May Improve Administrative Efficiency, which discusses the GAO’s findings and recommendations for increasing the consistency of requirements upon the various Centers for Medicare & Medicaid Services (CMS) Medicare fee-for-service contractors conducting post-payment review of claims. 

The report found that over time, Congress has provided for CMS to use contractors to carry out many different functions in connection with the Medicare fee-for-service (FFS) program, which has resulted in the use of several different types of contractors to conduct claims reviews. The multiple types of Medicare contractors performing post-payment reviews were established by different legislative actions; are managed by different offices within CMS; and have different characteristics and serve different primary functions in the program, all of which affect their use and conduct of post-payment claims reviews.

Currently, CMS uses: (1) Medicare Administrative Contractors (MAC), the contractors that process and pay claims, also conduct pre- and post-payment claims reviews and recoup overpayments or remediate underpayments; (2) Zone Program Integrity Contractors (ZPIC), which perform pre- and post-payment claims reviews as a part of investigating potential fraud; (3) Comprehensive Error Rate Testing (CERT) contractors, which estimate the Medicare FFS improper payment rate, in part by conducting post-payment claims reviews on a random sample of claims processed by the MACs; and (4) Recovery Auditors (RA) (also commonly known as Recovery Audit Contractors or RACs), which conduct data analysis and post-payment claims reviews to identify improper payments. 

All four types of Medicare contractors performing post-payment reviews conduct complex reviews, in which the contractor examines medical records and other documentation sent by providers to determine if the claims meet Medicare coverage and payment requirements.  GAO concluded that differences in CMS’s post-payment claims review requirements for the four types of contractors may reduce the efficiency and effectiveness of claims reviews by complicating providers’ compliance with the requirements.  Differences in requirements may have come about because the contractors’ requirements were developed at different times, the contractors’ activities have changed over time, or because different types of contractors and their associated requirements are managed by different parts of CMS. 

In order to improve the efficiency and effectiveness of Medicare program integrity efforts and simplify compliance for providers, GAO  recommends that: (1) the Administrator of CMS should examine all post-payment review requirements for contractors to determine those that could be made more consistent without negative effects on program integrity; (2) the Administrator of CMS should communicate publicly CMS's findings and its time frame for taking further action; and (3) the Administrator of CMS should reduce differences in post-payment review requirements where it can be done without impeding the efficiency of its efforts to reduce improper payments.  To obtain a copy of the complete GAO report, click here.

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