Government Accountability Office finds Medicare audits lack oversight

The Government Accountability Office  has recommended action from CMS to improve the efficiency and effectiveness of its contractors’ postpayment review efforts after a performance audit showed CMS has not conducted sufficient data monitoring to prevent recovery auditors from conducting inappropriate duplicate reviews.

The audit, conducted from April 2013 to July 2014, found that CMS “neither has reliable data nor provides sufficient oversight and guidance to measure and fully prevent duplication” among its contractors, which in addition to Recovery Auditors include Medicare Administrative Contractors, Zone Program Integrity and the Comprehensive Error Rate Testing contractor, according to the Government Accountability Office (GAO). The GAO report stated that postpayment contractors did not consistently enter information about their reviews in the CMS database, and CMS did not provide adequate guidance or make sure that contractors remained compliant.

“In the correspondence reviewed, GAO found high compliance rates for some requirements, such as citing the issues leading to an overpayment, but low compliance rates for requirements about communicating providers rights, which could affect providers’ ability to exercise their rights,” GAO stated in the report.

GAO stated it has designated CMS a high-risk program for the past 20 years “because of its size, complexity and susceptibility to mismanagement and improper payments.”

GAO issued the following four recommendations for CMS in its report:

  • To monitor the CMS database to ensure that contractors submit required data and that data is accurate and complete;
  • To develop guidance to make sure contractors’ responsibilities regarding duplicative claims reviews are defined;
  • To clarify and standardize content requirements for its contractors’ ADRs and results letters to ensure greater consistency; and
  • To conduct regular assessments to ensure that contractors comply with CMS requirements for claims review correspondence content.

The Department of Health and Human Services reviewed the report and has concurred with GAO findings and recommendations.

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