GAO report calls for more consistency investigating Medicare post-payment claims

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GAO report calls for more consistency investigating Medicare post-payment claims
GAO report calls for more consistency investigating Medicare post-payment claims

Government investigators claim — and the Centers for Medicare & Medicaid Services concurs — that more consistency is needed with Medicare post-payment claims reviews.

A new Government Accountability Office report says the number of different rules and procedures for Zone Program Integrity Contractors, Medicare Administrative Contractors, Recovery Audit Contractors and Comprehensive Error Rate Testing Contractors is confusing to healthcare providers. For example, providers have 30 days to respond to an Additional Documentation Request (ADR) sent by a ZPIC; 45 days to respond to an ADR sent by a MAC or RA; and 75 days to respond to an ADR sent by the CERT contractor, according to the report.

The American Health Care Association and LeadingAge were among the provider associations consulted for the OIG report, which was released Thursday.

The Department of Health and Human Services agreed with the GAO's recommendations and noted that CMS had begun an examination of its requirements for post-payment claims reviews. HHS also agreed to:

  • Examination of requirements related to ADRs to see if the requirements could be standardized across contractor types.
  • Consideration of standardizing the minimum number of days a contractor must give a provider to respond to an ADR before the contractor has the authority to deny the claim.
  • Publicly communicate its findings from the review of the requirements on CMS's website and include a time frame.

To read the Medicare Program Integrity: Increasing Consistency of Contractor Requirements May Improve Administrative Efficiency, click here.