GAO Report Identified Problems with CMS Contractors’ Postpayment Review Procedures

A recent report released by the Government Accountability Office (GAO) uncovered numerous issues related to the Center for Medicare & Medicaid Services” (CMS) general lack of oversight of its multiple contractors who conduct prepayment reviews. The GAO noted that these issues could lead to duplicate reviews and increased burdens for health care providers.

The GAO report noted that 83% of all postpayment claim reviews were conducted by Recovery Auditors (RAs) formerly referred to as Recovery Audit Contractors (RACs). The remaining postpayment claim reviews were conducted by Medicare Administrative Contractors (MACs), Zone Program Integrity Contractors (ZPICs) and Comprehensive Error Rate Testing (CERT) contractors.

The GAO found that not all contractors were consistently entering data in the Recovery Audit Data Warehouse and that specifically more than half of the ZPICs were not entering their claims reviewed as “exclusions”, thus resulting in the potential for duplicative reviews on the same claims.

Further the GAO found that the correspondence from the various contractors was not consistent. For example, at the time of the audit, RAs were not required to include overpayment amounts for each claim and ZPICs were not required to inform providers of Medicare’s right to recover payments and the right to charge interest. These discrepancies were, in part, related to inconsistent statements in the Medicare Program Integrity Manual.

In addition, the GAO noted that not all contractors gave providers the legally required amount of time to submit requested information.

The GAO specifically recommended that CMS take the following actions:

  1. Monitor the Recovery Audit Data Warehouse to ensure that all contractors are submitting the required data and to confirm that the database is accurate and complete.
  2. Develop complete guidance for all contractors related to duplicative claim reviews.
  3. Clarify and standardize ADR and results letters.
  4. Assess contractor compliance with correspondence content requirements regularly.

For more information about the Medicare appeals process, please contact one of our health law attorneys. Medicare appeals resources can be found on our Medicare appeals resource page.



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