GAO Inquiry: How Are CMS Post Payment Reviews Working?
Monday, January 14, 2013
by: VNAA Policy Team

Section: Public Policy and Advocacy

The Government Accountability Offices is doing a study on behalf of several members of Congress to better understand the Centers for Medicare and Medicaid Services’ strategy for Medicare program integrity efforts and provider input is being sought. GAO has a list of detailed questions that it wants to ask providers about the number of claims being reviewed, claims selection, provider communications, additional documentation requests (ADR), the skill of reviewers, and the review process as a whole. 
GAO notes that some provider groups have indicated that the written correspondence from the contractors is unclear and unhelpful, especially ADR letters and Notice of Review Results. GAO would like to see examples of such letters—redacted to remove provider and any beneficiary identifiers. 
VNAA will be meeting with GAO during the first week of February and wants to identify members who can address both problems and solutions related to the topics listed above. Please contact Katy Barnett ( and let us know if you: 1) have information to share including examples of unclear correspondence, 2) you can participate in a meeting with GAO either in person or by phone on February 4, 5, or 6, and 3) if you have answers to the prepared questions below.   
Please take a moment to review the following general questions provided by GAO and if you are able to provide feedback please click here and complete the simple online questionnaire or contact Katy Barnett as noted above.
CMS Oversight of Medicare Fee-for-Service Contractors
GAO will examine CMS’s oversight of four types of contractors that conduct Medicare post-payment claims reviews: Medicare Administrative Contractors, Recovery Auditors,[1] Zone Program Integrity Contractors,[2] and Comprehensive Error Rate Testing contractors. GAO is focusing its attention on the post-payment claims reviews and does not plan to address the appeals process.
Interview Questions
  1. Do your members have a coherent understanding of the reasons for the different contractors involved in post-payment claims’ reviews? Do they understand the contractors’ roles, responsibilities, and requirements of reviewing claims for improper payments?

A. Would a better understanding of the contractors’ purposes, roles, responsibilities and requirements improve the efficiency of claims processing and reviews?

  1. Have your members experienced an increase in claim reviews in the last few years? If so, to what do they attribute the increase?
  2. What are your members’ greatest concerns about reviews conducted by Medicare fee-for-service contractors?
  3. Have your members expressed concerns about being subject to duplicative claim reviews?  Do your members typically consider duplicative reviews as different contractors auditing the same claims? Or, do they consider different contractors auditing different claims from the same provider to be a duplicative review.

A. As appropriate, please provide specific examples of duplicative reviews.
B. Have your members or your organization followed up with CMS or the appropriate contractors concerning duplicative reviews? If so, what was the outcome?

  1. What actions should CMS or its contractors take to reduce improper payments for the services your members provide?
  2. Are there any other issues related to Medicare FFS contractors’ claim reviews that you would like to raise with GAO?

[1]Recovery auditors were formerly known as recovery audit contractors or RACs.
[2]We will not examine the work of the legacy Program Safeguard Contractor that is performing post-payment audits in Zone 6.
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