CMS could make postpayment reviews of claims more efficient and reduce the administrative burden for healthcare providers by making Medicare contractor requirements more consistent, according to a report from the U.S. Government Accountability Office.
There are four different types of contractors that review Medicare fee-for-service claims. Medicare Administrative Contractors process and pay claims and work to prevent payment errors; Zone Program Integrity Contractors investigate possible cases of fraud in their designated geographic areas; Recovery Auditors, or RACs, identify improper payments; and Comprehensive Error Rate Testing contractors review samples of claims and other documents to determine the improper payment rate for claims nationwide.
All of these contractors use the same general post-payment claims review process, but CMS has different requirements for the review procedure depending on the type of contractor, according to the GAO. For example, CERT contractors must give providers 75 days to respond for requests for documentation before the contractors can declare a claim improper because of a lack of documentation. ZPIC entities only have to give providers 30 days to respond.
These differing requirements potentially reduce efficiency and effectiveness, and they increase the administrative burden placed on providers being audited, according to the GAO. The GAO recommends CMS examine its claims review requirements for contractors and determine how to make them more consistent. CMS should then announce its findings and its plan for taking action. The agency should work to eliminate differences in a way that doesn't interfere with improper payment reduction efforts, according to the GAO. CMS has begun examining the requirements, according to the report.
CMS invited Medicare fee-for-service providers to evaluate their MACs last month. The agency plans to use the results to increase efficiency, monitor trends and improve oversight.
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