Tuesday, December 10, 2013

GAO Medicare Program Integrity Report Shows Improvements Needed

By Dianne De La Mare

The US General Accounting Office (GAO) has released a report, Medicare Program Integrity:  Contractors Reported Generating Savings; BUT CMS Could Improve Its Oversight, indicating that Centers for Medicare & Medicaid Services (CMS) Medicare contractors have generated savings; but the agency should improve its oversight.  According to the report, in 2012, the cost-saving activities of Zone Program Integrity Contractors (ZPICs) were associated with a reported $251.9 million in associated savings to Medicare. In 2012, CMS gave close to $108 million to six operating ZPICs, most of which ($77 million) went toward reimbursing contractors for their fee-for-service work.  Despite CMS’ sizeable investment and the savings generated by the ZPICs; the GAO report stated that CMS lacks the information necessary for determining whether additional savings could be generated.  Additionally, CMS’ approach to addressing Medicare fraud is reactive instead or proactive. Of the 5,000 investigations of potential Medicare fraud that were carried out in 2012, close to 90 percent were in response to complaints, according to the report.  CMS also failed to link ZPIC performance to its program integrity measures.  GAO ask CMS to consider the following recommendations:  1) Collect and evaluate information on the timeliness of ZPICs’ investigative and administrative actions, such as how soon investigations are initiated after ZPICs identify potential fraud and how swiftly ZPICs initiate administrative actions after identifying potentially fraudulent providers; and 2) Develop ZPIC performance measures that explicitly link their work to the agency’s Medicare fee-for-service program integrity performance measures and targets for its Government Performance and Results Act (GPRA) goal of fighting fraud and working to eliminate improper payments.  To read the complete report, click here.

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