Government Accountability Office calls for CMS to fix auditing process

The Centers for Medicare & Medicaid Services (CMS) doesn't do enough to prevent duplicative reviews of provider payments, according to a new report from the Government Accountability Office (GAO).

The report looked at four types of contractors:

  • Medicare adminstrator contractors (MACs), who process and pay claims
  • Zone program integrity contractors (ZPICs), who investigate potential fraud
  • Recovery audit contractors (RACs), who investigate improper payments not previously reviewed by other contractors
  • Comprehensive error rate testing (CERT) contractors, who reviews claims used to annually estimate Medicare's improper payment rate

Although CMS has made progress on contractor oversight, the report states it fails to ensure that auditors don't review payments twice. While contractors must include certain content when corresponding with providers during the postpayment review process, "some requirements vary across contractor types and are not always clear, and contractors vary in their compliance with their requirements," the report states.

As a result, according to the report, providers may receive less information on the reviews, which hurts communication. Just how much CMS oversees correspondence also varies by contractor, making it harder to ensure consistent compliance with requirements across contractors. GAO found high compliance rates in some categories, such as citing the issues that led to an overpayment, but low compliance for other requirements, such as clearly establishing providers' rights.

Although CMS has strategies in place to internally coordinate on review requirements, "these strategies have not led to consistent requirements across contractor types," the report adds.

The report reinforces the need for CMS to fix the auditing process, Sen. Orrin Hatch (R-Utah), ranking member of the Senate Finance Committee, told The Hill. "CMS has a duty to safeguard scarce taxpayer dollars and streamline postpayment claims reviews, but as GAO says, it has failed to do so," he said. "CMS' current efforts to coordinate with contractors in reducing duplicative programs are simply inadequate."

RACs in particular have long attracted criticism; in late June, a lawsuit caused CMS to delay awarding new RAC contracts until mid-August rather than early June, FierceHealthFinance previously reported.

To learn more:
- read the report
- here's the article