Home Health & Hospice

GAO advices CMS to ramp up oversight and guidance for postpayment claims reviews

Homecare Insider, August 18, 2014

A new report from the U.S. Government Accountability Office (GAO) found that CMS does not have reliable data or sufficient oversight to measure and prevent duplicative postpayment claims reviews.
The July study, entitled “Medicare Program Integrity: Increased Oversight and Guidance Could Improve Effectiveness and Efficiency of Postpayment Claims Reviews,” gauges CMS’ management of postpayment claims reviews conducted by Medicare contractors—a task kindled by industry concerns surrounding the effectiveness, efficiency, and burden that the claims review process for ensuring proper payment puts on providers. Specifically, the report examines CMS’ access to data for assessing whether contractors conduct duplicative postpayment claims reviews, as well as the organization’s requirements for correspondence between contractors and providers, and finally, its strategies for coordinating claims reviews activities.
Currently, GAO reports that there is a dearth of reliable data and oversight, inconsistent contractor guidance and requirements, and noncompliance with CMS requirements.
To remedy these problems, GAO recommends that CMS provide additional oversight and guidance regarding data, duplicative reviews, and contractor correspondence. In particular, it advices CMS to:
  • Monitor the Recovery Audit Data Warehouse to ensure required data is submitted, accurate, and complete
  • Develop complete guidance to define contractors’ responsibilities
  • Clarify the current requirements regarding contractors’ communications with providers
  • Assess regularly whether contractors are complying with requirements