CMS Not Doing Enough To Prevent Duplicate Audits, GAO Says
CMS is not doing enough to make sure Medicare provider payment audits are not duplicated, according to a Government Accountability Office report released Wednesday, The Hill reports.
The report noted that while CMS has stepped up its oversight of its contractors, it must do more to ensure that auditors are not completing duplicative reviews. According to the report, CMS cannot reliably ensure duplicate audits are not being conducted.
The report stated, "CMS requires its contractors to include certain content in post-payment review correspondence with providers, but some requirements vary across contractor types and are not always clear, and contractors vary in their compliance with their requirements" (Al-Faruque, The Hill, 8/13).
Specifically, the report found that CMS has not provided enough guidance to make sure that work is not duplicated between the four different groups that audit improper payments. Those groups are:
- Comprehensive error rate testing contractors, which are responsible for reviewing claims to determine Medicare's annual improper payment rate;
- Medicare administrative contractors, which pay and process claims;
- Recovery audit contractors, which look at payments that have not already been reviewed by other contractors; and
- Zone program integrity contractors, which look into cases of potential fraud.
For example, the report noted that in 2011, a RAC had to cease reviewing 2,000 claims because it was not informed that a ZPIC already was conducting an ongoing investigation into the claims. The report noted, "Without complete guidance for all post-payment claims review contractors about when duplicative reviews are permitted, CMS does not have assurance that MACs and ZPICs understand when and how to avoid duplicative reviews" (Young, CQ HealthBeat, 8/13).
GAO recommended that CMS improve its contractor oversight and issue guidance on auditor data, contractor communications and duplicate reviews. According to GAO, CMS agrees with the suggestions and is working to put them in place (The Hill, 8/13).
Lawmakers Highlight Need for More Oversight
Several lawmakers called for the report (CQ HealthBeat, 8/13). The lawmakers have criticized the auditing process, which they say threatens health care providers with long, frivolous investigations. In addition, federal legislators have said CMS does not do enough to ensure providers are not penalized for administrative mistakes or duplicative reviews by multiple auditors (The Hill, 8/13).
However, the lawmakers said the report can be used as a basis for "Congress and CMS to help make improvements and ensure more consistent oversight of both the contractors and audit process" (CQ HealthBeat, 8/13).
Sen. Orrin Hatch (R-Utah) said the report shows that CMS must do more to oversee the process, adding, "CMS has a duty to safeguard scarce taxpayer dollars and streamline post-payment claims reviews, but as GAO says, it has failed to do so" (The Hill, 8/13). He continued, "By establishing clear guidance and communication with its contractors, as recommended by this report, CMS can strengthen the post-payment audit review process to better serve contractors and taxpayers alike" (CQ HealthBeat, 8/13).This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.