CMS must provide better oversight to prevent duplicate audits says GAO study

August 14, 2014
Area(s) of Interest: Fraud & Abuse 

A newly released study by the federal General Accounting Office (GAO) found that the Centers for Medicare and Medicaid Services (CMS) needs to provide better oversight and guidance for provider payment auditors to prevent duplicative post-payment claims review audits.

Several types of Medicare contractors conduct postpayment claims reviews to help reduce improper payments: Medicare Administrative Contractors, which process and pay claims; Zone Program Integrity Contractors, which investigate potential fraud; Recovery Auditor Contractors, tasked with identifying on a postpayment basis improper payments not previously reviewed by other contractors; and the Comprehensive Error Rate Testing contractor, which reviews claims used to annually estimate Medicare's improper payment rate. 

The report notes that although CMS implemented a database to track audit activities, designed in part to prevent duplicative audits by multiple contractors, it must do more to ensure that auditors are not completing duplicative reviews. The report notes that the database was not designed to provide information on all possible duplication, and found that it's data is not reliable because other postpayment contractors do not consistently enter information about their reviews.

The report concludes that CMS has not provided sufficient oversight of this data or issued complete guidance to contractors on avoiding duplicative claims reviews.

GAO recommends that CMS take actions to improve the efficiency and effectiveness of contractors' post-payment review efforts, which include providing additional oversight and guidance regarding data, duplicative reviews and contractor correspondence. In its comments, the U.S. Department of Health and Human Services concurred with the recommendations and noted plans to improve CMS oversight and guidance.

Click here to read the full report.


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