Medicare Could Do More to Stop Duplicate Payments to Providers

Goncharuk Maksim/

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.

(Image via Goncharuk Maksim/

Stay up-to-date with federal news alerts and analysis — Sign up for GovExec's email newsletters.
Close [ x ] More from GovExec

Thank you for subscribing to newsletters from
We think these reports might interest you:

  • Sponsored by G Suite

    Cross-Agency Teamwork, Anytime and Anywhere

    Dan McCrae, director of IT service delivery division, National Oceanic and Atmospheric Administration (NOAA)

  • Data-Centric Security vs. Database-Level Security

    Database-level encryption had its origins in the 1990s and early 2000s in response to very basic risks which largely revolved around the theft of servers, backup tapes and other physical-layer assets. As noted in Verizon’s 2014, Data Breach Investigations Report (DBIR)1, threats today are far more advanced and dangerous.

  • Sponsored by One Identity

    One Nation Under Guard: Securing User Identities Across State and Local Government

    In 2016, the government can expect even more sophisticated threats on the horizon, making it all the more imperative that agencies enforce proper identity and access management (IAM) practices. In order to better measure the current state of IAM at the state and local level, Government Business Council (GBC) conducted an in-depth research study of state and local employees.

  • Sponsored by Aquilent

    The Next Federal Evolution of Cloud

    This GBC report explains the evolution of cloud computing in federal government, and provides an outlook for the future of the cloud in government IT.

  • Sponsored by LTC Partners, administrators of the Federal Long Term Care Insurance Program

    Approaching the Brink of Federal Retirement

    Approximately 10,000 baby boomers are reaching retirement age per day, and a growing number of federal employees are preparing themselves for the next chapter of their lives. Learn how to tackle the challenges that today's workforce faces in laying the groundwork for a smooth and secure retirement.

  • Sponsored by Hewlett Packard Enterprise

    Cyber Defense 101: Arming the Next Generation of Government Employees

    Read this issue brief to learn about the sector's most potent challenges in the new cyber landscape and how government organizations are building a robust, threat-aware infrastructure

  • Sponsored by Aquilent

    GBC Issue Brief: Cultivating Digital Services in the Federal Landscape

    Read this GBC issue brief to learn more about the current state of digital services in the government, and how key players are pushing enhancements towards a user-centric approach.


When you download a report, your information may be shared with the underwriters of that document.