On August 22, the U.S. Government Accountability Office (GAO) released a report calling for the Centers for Medicare & Medicaid Services (CMS) to improve the efficiency and effectiveness of its Medicare program integrity contractors. The GAO report emphasized a particular need to increase consistency among the contractors, noting how the differing claims review processes used by the contractors confuse providers and complicate efforts at compliance. The report, titled Medicare Program Integrity: Increasing Consistency of Contractor Requirements May Improve Administrative Efficiency (GAO-13-522), arose at the request of a bipartisan group of senators and congressmen examining the issue.
The report reviewed the extent to which the contractors' postpayment reviews are effective in detecting improper payments, weighed against the extent these reviews add an unnecessary and costly administrative burden to providers. The report focused on Medicare fee-for-service claims and providers.
The report also serves as a useful primer on Medicare contractors, as GAO made efforts to explain each contractor type (i.e., Medicare administrative contractors (MACs), zone program integrity contractors (ZPICs), comprehensive error rate testing (CERT) contractors, and recovery auditors (RAs)) to differentiate their varying roles and responsibilities.
When conducting postpayment claims reviews, contractors are expected to apply the same criteria (i.e., regulations, coverage, and coding policies) to determine whether or not a claim was properly paid. The GAO report stated that ineffective or inefficient claims reviews pose the risk of generating false findings of improper payments, and can impose an unnecessary administrative and financial burden on the Medicare providers required to appeal these denials.
The report contained the following notable findings:
GAO recommended CMS take the following steps to address contractor inconsistencies:
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