The U.S. Government Accountability Office (GAO) recently published the results of a study examining the effectiveness of CMS’s contractors that conduct postpayment claims reviews to identify improper payments (i.e., Medicare Administrative Contractors, Zone Program Integrity Contractors, Recovery Auditors, and Comprehensive Error Rate Testing contractors). In its report, the GAO assesses the extent to which requirements, methods, and standards applied during postpayment claims reviews differ across contractors. Although postpayment claims reviews involve similar processes regardless of which type of contractor conducts them, CMS has different requirements for many aspects of the process across the four contractor types. For example, there are differences in time frames for providers to send in documentation, content of communications to providers about the reviews, reviewer staffing, and the designation of criteria used to determine whether a service is paid improperly. Providers indicated that some differences hindered their understanding of and compliance with the claims review process. The GAO set out to determine whether these differences, if any, could impede effective and efficient claims reviews.

GAO recommends, among other things, that CMS do the following in order to increase consistency across Medicare contractors:

  • Examine all contractor postpayment review requirements to determine those that could be made more consistent;  
  • Communicate its findings and time frame for taking action; and  
  • Reduce differences where it can be done without impeding efforts to reduce improper payments.

The Department of Health and Human Services noted that CMS had begun examining requirements for streamlining postpayment reviews across the various contractors and otherwise concurred with GAO’s recommendations to reduce differences in postpayment review requirements.

CMS estimated that $32.4 billion in Medicare fee-for-service payments in FY 2012 were improper. GAO’s July 23, 2013 report is available here. See also K&S’s Health Headlines article discussing CMS’s announcement of Unified Program Integrity Contractors, available here.