Medicare managers’ ongoing efforts to avoid duplicate payments to health care providers could benefit from improvements to post-payment reviews by contractors, a recent audit found.
The Centers for Medicare and Medicaid Services “does not have sufficient information to determine whether its contractors are conducting inappropriate duplicative claims reviews” due to inadequate data monitoring, the Government Accountability Office said in a recently released report completed in July.
Medicare fraud is a key contributor to the governmentwide improper payments estimated at $1.6 billion annually. Auditors sampled contractor reviews of 1.4 million claims by hospitals, doctors, laboratories, skilled nursing services, home care providers and ambulance services in 2012.
To identify suspicious claims and estimate error rates, four types of review contractors select claims, request documentation from providers to support Medicare coverage of those claims, apply Medicare coverage and coding requirements to determine if the claims were paid properly and communicate the results of their reviews to the providers.
Though progress is evident and guidance has been formulated, the main CMS “database was not designed to provide information on all possible duplication, and its data are not reliable because other postpayment contractors did not consistently enter information about their reviews,” GAO found. “CMS has not provided sufficient oversight of these data or issued complete guidance to contractors on avoiding duplicative claims.”
Because of inconsistent approaches by contractors, GAO also found that correspondence with providers often lacks key information that allows those providers to contest any alleged overpayments.
GAO recommended that CMS take provide “additional oversight and guidance regarding data, duplicative reviews and contractor correspondence.” The Health and Human Services Department, on reviewing a draft of the report, largely agreed.
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