GAO Report to Congressional Requesters: Medicare Program Integrity

On August 13, 2014, the GAO released a report on the effectiveness of post-payment audits. The American Association for Homecare has met twice with the GAO specifically about audit activity. The last meeting occurred on September 17, 2013 and included AAHomecare supplier members from across the country. Our focus in the meeting was on the burdens imposed by audits focusing on the volumes of MAC pre-pay audits with the goal of impressing on the GAO that pre-pay and post-pay audits are virtually the same – except there is even less over-sight on contractor requirements in terms of volumes, operational processes and overall goals of the pre-pay audit.

In this report the GAO indicates that only 13 associations were interviewed on the topic to gather data; AAHomecare provided input on behalf of the DMEPOS sector.

The report focused on audits from April 2013 through July 2014. Although the report centered on post-payment audits, the conclusions reached by the GAO are reflective of the issues AAHomecare brought up in discussions.

The GAO found that CMS does not have reliable data to estimate the volumes of duplicate claim audits and the mechanism to monitor this has little oversight. In addition direction provided by CMS to MACs and ZPICs on whether duplicate audits can be conducted is lacking to the point that some contractors think they can do duplicate audits and some do not.

Currently the individual audit contractors report through different channels within the CMS structure and this has caused inconsistencies for providers.

The report also focused on additional document requests (ADR) and the inconsistencies between audit contractors with regards to:

    • time frames for responses

• what needed to be included in the response

• the reason for the audit

• whether the audit contractor had to issue a results letter to the provider

The GAO further indicated that providers may have difficulty exercising their rights when result letters are limited and can have financial consequences due to this.

There were several statements in the report where CMS indicated that audit contractors were doing a good job, including statements noting that ZPIC claim reviews were typically satisfactory and the RAC accuracy rates for 2012 were 93-97%. Nonetheless, it is clear the GAO identified many areas of improvement for CMS.

The findings in the GAO report support the provisions of Congresswoman Renee Ellmer’s recently introduced legislation, H.R. 5083 – The Medicare DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies) Audit Improvement and Reform (AIR) Act of 2014. The goal of this legislation is to set some standards around how the audit process works.

AAHomecare will continue to follow-up with the GAO on audit issues; including a focus on pre-payment audits. To view the entire report, click here.

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