GAO identifies ways to fix Medicare audits

CMS should improve the efficiency and effectiveness of contractors' post-payment reviews, according to a U.S. Government Accountability Office report.

Several different types of Medicare contractors carry out post-payment claims reviews to identify and retrieve improper payments. However, there have been concerns surrounding their effectiveness, efficiency and the burden they place on providers, prompting the GAO to assess the review process. The GAO has concluded that CMS needs to provide additional oversight and guidance concerning data, duplicative reviews and contractor correspondence.

The four types of contractors the GAO reviewed include Medicare administrative contractors, which process and pay claims; Zone program integrity contractors, which investigate possible fraud cases; recovery auditors, which seek to identify improper payments not previously reviewed by other contractors; and comprehensive error rate testing contractors, which review claims used to annually estimate Medicare's improper reimbursement rate.

Although CMS has created a database to track RA activity and prevent review duplication, the database isn't designed to include details on all possible duplication, and post-payment contractors haven't consistently provided information about their reviews. Furthermore, CMS hasn't provided sufficient oversight or issued complete guidance to contractors on avoiding claims review duplication, according to the GAO.

Additionally, CMS' requirements concerning what content is included in post-payment review correspondence with providers vary across contractor types and aren't always clear. CMS' oversight of correspondence also varies across contractors.

HHS agrees with the GAO's recommendations to improve the efficiency and effectiveness of post-payment reviews and has plans to improve CMS oversight and guidance, according to the report.

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