GAO Report Calls For Reforms to CMS Post Payment Review System

Re-posted from VNAA

The Government Accountability Office (GAO) released a report calling for the Centers for Medicare and Medicaid Services (CMS) to “take actions to improve the efficiency and effectiveness of contractors’ post payment review efforts, which include providing additional oversight and guidance regarding data, duplicative reviews and contractor correspondence” with providers. The report had been requested by a bipartisan group of House and Senate members and looked at coordination across Medicare’ (MAC) claims processing functions; Zone Program Integrity Contractors’ (ZPIC) fraud investigation; Recovery Auditors’ (RA) post payment reviews, which seek to identify “improper payments not previously reviewed by other contractors”; and the Comprehensive Error Rate Testing (CERT) contractor’s review of “claims used to annually estimate Medicare’s improper payment rate.” While noting some CMS efforts to coordinate among contractors, such as implementing a database for tracking RA activities, GAO says “CMS has not provided sufficient oversight of these data or issued complete guidance to contractors on avoiding duplicative claims reviews.” Specific GAO recommendations include that CMS seek to “improve the efficiency and effectiveness of Medicare post payment claims review efforts and simplify compliance for providers” through four approaches:

“Monitor the Recovery Audit Data Warehouse to ensure that all post payment review contractors are submitting required data and that the data the database contains are accurate and complete;
Develop complete guidance to define contractors’ responsibilities regarding duplicative claims reviews, including specifying whether and when MACs and ZPICs can duplicate other contractors’ reviews;
Clarify the current requirements for the content of contractors’ [Additional Documentation Requests] and results letters and standardize the requirements and contents as much as possible to ensure greater consistency among post payment claims review contractors’ correspondence; and
Assess regularly whether contractors are complying with CMS requirements for the content of correspondence sent to providers regarding claims reviews.”

CMS stated they agree with the findings of the GAO report, and said in a letter included in the final GAO report that they are making steps to address the GAO’s findings.

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