The Government Accountability Office (GAO) released a report titled “Increasing Consistency of Contractor Requirements May Improve Administrative Efficiency.” GAO undertook the study at Congress’ request because questions have been raised recently about the efficiency and effectiveness of claim reviews by the four different types of Medicare contractors, which include MACs, ZPICs, RAs, and CERTs.
GAO found that the contractors followed the same general process for postpayment claim reviews, but that CMS has different requirements for each of the contractors. Process differences involve oversight in claims selection, time frame for providers to send documentation, communication to providers about reviews, reviewer staffing, and processes to ensure the quality of claim reviews. GAO believes that these differences may impede the efficiency and effectiveness of claim reviews and place an undue administrative burden on providers.
The report recommends that CMS take the following actions, all of which are supported by the Department of Health and Human Services.
The report notes that CMS has already begun implementing the first recommendation.
- Examine all contractor postpayment review requirements to determine those that could be made more consistent.
- Communicate its findings and time frame for taking action.
- Reduce differences where it can be done without impeding efforts to reduce improper payments.
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