Report: Long-term care providers pay the price for CMS' poor auditor oversight

Long-term care and other providers could be facing unfair burdens due to ineffective government oversight of Medicare auditors, according to a new report from a federal watchdog agency.

The Centers for Medicare & Medicaid Services does keep a database to track Recovery Audit Contractor activity and prevent them from reviewing the same claim multiple times, a Government Accountability Office investigation determined. However, the three other types of auditors do not consistently enter information into this database. RACs explicitly are not allowed to review claims that have been evaluated by other contractors, but CMS has not “developed complete guidance” about whether non-RAC auditors can undertake duplicative reviews.

“CMS neither has reliable data nor provides sufficient oversight and guidance to measure and fully prevent duplication,” the GAO investigators stated in the report released Wednesday.

Claims reviews generate work both for providers and contractors, so inappropriate duplication could create burdens for both groups, the GAO noted. In addition to RACs, post-payment reviews are done by Medicare Administrative Contractors, Zone Program Integrity Contractors and Comprehensive Error Rate Testing Contractors.

Lack of coordination among the various auditors has led to problems in other areas, the GAO determined. For instance, the different contractors have varying requirements for what has to be in post-payment review correspondence with providers. And contractors have varying levels of compliance with the requirements; most include information about what issues led to overpayment, but GAO found “low compliance rates” for including information about what rights the provider can exercise in the review process.

The investigators examined policy manuals, conducted interviews, and analyzed claims, auditing and contract information to compile the report. It recommended that CMS take a number of steps to tighten oversight of contractors and simplify their compliance, such as by issuing more complete guidance. CMS concurred with the recommendations.