Medicare Could Do More to Stop Duplicate Payments to Providers

Goncharuk Maksim/Shutterstock.com

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/Shutterstock.com)

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

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

  • Going Agile:Revolutionizing Federal Digital Services Delivery

    Here’s one indication that times have changed: Harriet Tubman is going to be the next face of the twenty dollar bill. Another sign of change? The way in which the federal government arrived at that decision.

    Download
  • Cyber Risk Report: Cybercrime Trends from 2016

    In our first half 2016 cyber trends report, SurfWatch Labs threat intelligence analysts noted one key theme – the interconnected nature of cybercrime – and the second half of the year saw organizations continuing to struggle with that reality. The number of potential cyber threats, the pool of already compromised information, and the ease of finding increasingly sophisticated cybercriminal tools continued to snowball throughout the year.

    Download
  • Featured Content from RSA Conference: Dissed by NIST

    Learn more about the latest draft of the U.S. National Institute of Standards and Technology guidance document on authentication and lifecycle management.

    Download
  • GBC Issue Brief: The Future of 9-1-1

    A Look Into the Next Generation of Emergency Services

    Download
  • GBC Survey Report: Securing the Perimeters

    A candid survey on cybersecurity in state and local governments

    Download
  • The New IP: Moving Government Agencies Toward the Network of The Future

    Federal IT managers are looking to modernize legacy network infrastructures that are taxed by growing demands from mobile devices, video, vast amounts of data, and more. This issue brief discusses the federal government network landscape, as well as market, financial force drivers for network modernization.

    Download
  • eBook: State & Local Cybersecurity

    CenturyLink is committed to helping state and local governments meet their cybersecurity challenges. Towards that end, CenturyLink commissioned a study from the Government Business Council that looked at the perceptions, attitudes and experiences of state and local leaders around the cybersecurity issue. The results were surprising in a number of ways. Learn more about their findings and the ways in which state and local governments can combat cybersecurity threats with this eBook.

    Download

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