In 2016, an estimated $41.1 billion in improper Medicare fee-for-services payments were made to providers. The Centers for Medicare & Medicaid Services (CMS) believes that provider education plays an important role in ensuring payments are made properly; CMS has delegated authority for provider education to the Medicare Administrative Contractors (MACs).
In a recent report, the Government Accounting Office (GAO) found that contrary to federal internal control standards, CMS has not required the MACs to report on specific provider education efforts, which left certain areas vulnerable to improper billing. In addition, CMS has not required the MACs to educate providers who refer patients for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) and home health services on supporting billing documentation and referral documentation, also contrary to federal internal control standards.
The GAO recommended that CMS take steps to strengthen oversight and to ensure that provider education efforts are focused on areas that are vulnerable to improper billing. The GAO recommended, and CMS concurred, that CMS should require MACs to provide detailed reports on their provider education efforts. In addition, the GAO called for all MACs to collaborate to educate referring providers regarding the documentation requirements for DMEPOS and home health services. Finally, the GAO recommended that CMS establish performance metrics to determine the effectiveness of certain reviews in reducing improper billing.