Provider education efforts on improper billing need improvement, GAO says

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The Centers for Medicare & Medicaid Services has missed out on opportunities to improve provider education as a way to combat improper Medicare payments, a government watchdog reported on Monday.

Programs conducted by Medicare administrative contractors to educate providers on coverage and payment policies “play an important role” in cutting the rate of improper payments, the Government Accountability Office said in its report. But those education efforts could be improved with increased oversight and data reporting, the agency said.

Sufficient data is critical to making sure the MACs' education efforts are targeting the areas most prone to improper billing. Without it, the GAO said, CMS can't make sure the MACs are focusing on the areas that require the most education.

Medicare claims filed by skilled nursing facilities were identified by the report as being vulnerable for improper billing, especially claims for residents receiving Ultra High therapy.

The GAO's findings also took issue with the lack of education efforts for providers who refer patients for durable medical equipment and home health services, as well as CMS' failure to determine how effective its “probe and educate” reviews are at reducing improper billing.

The watchdog recommended that CMS require MACs to report sufficient detail into their education efforts; require that certain MACs collaborate to educate providers on documentation requirements for DME and home health; and establish performance metrics for future reviews. The Department of Health and Human Services agreed with the GAO's recommendations.