CMS Issues Transmittals Related to Duplicate Claim Reviews and Suspension of Payments
September 14, 2016 09:50 AM
The Centers for Medicare & Medicaid Services has issued Change Request (CR) 9665 forbidding Medicare post payment review contractors from performing duplicative claims reviews.
The CR is being issued in response to a U.S. Government Accountability Office (GAO) report 14-474 that found CMS did not have effective internal controls to prevent post payment review contractors from duplicating claim reviews.
The policy applies the Medicare Administrative Contractors (MAC), the Recovery Audit Contractors (RAC), and the Supplemental Medical Review Contractors (SMRC). The Comprehensive Error Rate Testing (CERT) contractors are permitted to duplicate another contractor’s review, when appropriate, if those claims are chosen as part of a statistically valid random sample to measure improper payment rates. In addition, the Zone Program Integrity Contractors (ZPIC) may duplicate a claim review in order to support their case development or other administrative action.
CMS has also issued CR 9396 which revises payment suspension procedures conducted by the ZPIC.
The ZPIC refers overpayments to the MAC only after the investigation has been vetted with CMS. Suspension of payment (“payment suspension”) may be approved when there is reliable information that an overpayment exists, when payments to be made may not be correct, or when there is a credible allegation of fraud existing against a provider. The ZPIC is responsible for advising and coordinating the imposition of a payment suspension with the appropriate MAC when a payment suspension has been approved by CMS. The ZPIC performs the necessary medical review and development of overpayments for payment suspensions that have received CMS approval, when appropriate.
If a payment suspension is approved for a home health agency, all Requests for Anticipated Payments (RAPs) are to be suppressed in accordance with 42 C.F.R. §409.43(c)(2). The ZPIC is to make this request to the CMS Center for Program Integrity as part of its request for a payment suspension.
In addition, CMS may suppress RAP payments for program integrity concerns absent a payment suspension. If the ZPIC determines that a RAP suppression is appropriate they shall submit the following information to CMS:
Are final bills being submitted by the HHA? Yes or No;
Indicate the volume (dollar and number of claims) of RAPs for the past 12 months;
A brief summary supporting the request for RAP suppression.