Tuesday, January 21, 2014

OIG Reports MAC Performance Needs Improvement

In January, the US Department of Health and Human Services, Office of Inspector General (OIG), released a report, Medicare Administrative Contractors’ Performance, which concludes that although the Medicare Administrative Contractors (MACs) met the majority of quality assurance standards; they failed to meet even one quarter of the performance standards reviewed by the Centers for Medicare and Medicaid Services (CMS), and the MACs also failed to resolve issues with 27 percent of those unmet standards.  CMS requires each MAC to develop and implement a quality control plan.  This plan specifies procedures to ensure that MAC services meet contract performance requirements.  CMS also must develop Quality Assurance Surveillance Plans(QASPs), which contain specific standards and methods for evaluating MAC work against performance requirements.  In addition to reviewing quality control plans and QASPS, and determining award fees; CMS also requires other performance monitoring.  MAC standards have stringent performance requirements -- a number of standards require 100 percent performance compliance.  

The OIG report indicates that CMS did not require action plans for 12 percent of the unmet standards, and unmet standards without action plans were almost four times more likely to have issues go unresolved.  MACs can earn award fees if their performance exceeds basic requirements, and metrics are included in MACs award fee plans to encourage improved performance.  However, certain areas identified as problematic through quality assurance review were not always included as metrics in MACs’ award fee  plans.  

Two MACs consistently underperformed across various CMS review, and CMS’ review of MACs, while extensive, were not always timely.  The OIG report recommended that CMS:  1) require action plans for all quality assurance standards not met; 2) use results of quality assurance reviews to help select award feed metrics for review; 3) meet timeframes for completing quality assurance reports; 4) meet timeframes for completing award fee determinations;  5) establish reasonable timeframes for issuing contractor performance reports; and 6) seek legislative change to increase the time between MAC contract competitions to give CMS more flexibility in awarding new contracts when MACs are not meeting CMS requirements.  To obtain a copy of the entire report go to OIG’s website at http://go.usa.gov/ZvsH

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