GAO Report: Medicare Contractors Should Coordinate More in Hunt for Improper Payments
September 25, 2014 10:52 AM
As reported recently in CQ HealthBeat, a new Government Accountability Office (GAO) report, Increased Oversight and Guidance Could Improve Effectiveness and Efficiency of Postpayment Claims Reviews, found that Medicare contractors hired to prevent Medicare from paying needlessly for services sometimes overlap in their efforts. GAO found that there has not been enough guidance from the Centers for Medicare and Medicaid Services (CMS) to prevent overlap in the work of the four kinds of businesses used to check for improper payments.
The GAO recommends that CMS take actions to improve the efficiency and effectiveness of contractors’ postpayment review efforts, which include providing additional oversight and guidance regarding data, duplicative reviews, and contractor correspondence. That step would spare doctors, hospitals and other providers of health services from duplicate reviews.
Medicare, which pays for health services for more than 50 million elderly and disabled Americans, is one of the largest expenses of the federal government, with an expected outlay of $595 billion for the current budget year, GAO said. As much as $36 billion of Medicare spending may go to improper payments. To combat this kind of loss, CMS relies on four different kinds of contractor. Providers of health services have told lawmakers that they have concerns about the consistency and accuracy of this complex audit process.
The four types of contractors are:
Medicare Administrative Contractors (MACs), which process and pay claims;
Zone Program Integrity Contractors (ZPICs), which investigate potential fraud cases;
Recovery Audit Contractors (RACs), which examine payments not previously reviewed by other contractors;
Comprehensive Error Rate Testing (CERT) contractors, which review claims to estimate annually what Medicare’s improper payment rate is.
Lawmakers are interested in the report findings. “The information in this report can now be used by Congress and CMS to help make improvements and ensure more consistent oversight of both the contractors and audit process,” the lawmakers said in a joint statement about GAO’s findings.
Among the lawmakers requesting information were Ron Wyden, (D-OR), the Chairman of the Senate Finance Committee; that panel’s ranking Republican, Orrin G. Hatch (R-UT); Fred Upton, (R-MI), the chairman of the Energy and Commerce Committee; and that panel’s ranking member, Henry A. Waxman (D-CA) and Charles Boustany, (R-LA), the chairman of the Ways and Means subcommittee on oversight and that panel’s ranking member, John Lewis (D-GA).