GAO releases report on Medicare contractors
Tuesday, August 27, 2013
by: VNAA Advocacy Team

Section: Public Policy and Advocacy

On Aug. 22, the Government Accountability Office (GAO) released a report on the four Medicare program integrity contractors specifically focusing on post-payment reviews.  This year, VNAA met with both GAO and the Centers for Medicare and Medicaid Services (CMS) to express concern about the post-payment review process.

On April 5, VNAA sent a letter to the Government Accountability Office (GAO) as a follow up to a February meeting at which VNAA members and staff presented a comprehensive list of concerns regarding Medicare audits on home health and hospice agencies. The letter outlines key concerns of members and provides recommendations for changing the audit process including the need to:

1)      Train and provide quality control for auditing staff;
2)      Provide transparency, clear requests and a firm timetable for auditors to respond;
3)      To ensure that auditing staff receiving clear training and guidance with regard to new legislative/regulatory change;
4)      Utilize current data from auditors to better target outliers and reduce administrative burden on small/rural agencies; and
5)      Rework the appeal process to address the fact that many of the audit denials are overturned at the Administrative Law Judge level.
To read VNAA’s letter to GAO, please click here.
The GAO report found that different post-payment claims review processes among four Medicare program integrity contractors are reducing effectiveness and confusing providers. The GAO makes the following recommendations to the Centers for Medicare and Medicaid Services (CMS):
1)      Examine all contractor post-payment review requirements to determine those that could be made more consistent,
2)      Communicate its findings and time frame for taking action, and
3)      Reduce differences where it can be done without impeding efforts to reduce improper payments. In its comments, the Department of Health and Human Services concurred with these recommendations, agreed to reduce differences in post-payment review requirements where appropriate, and noted that CMS had begun examining these requirements.
One area of concern for VNAA members was the inconsistent timelines for responding to audits. The study found that Zone Program Integrity Contractors (ZPICs) give providers 30 days to respond to a request for additional documentation on a reviewed claim before deeming it improper, compared with the 75 days given to providers by Comprehensive Error Rate Testing contractors (CERTs). Medicare Administrative Contractors (MACs) and Recovery Audit Contractors (RACs) give providers 45 days to respond. GAO found that these differences in claims review requirements may reduce efficiency and effectiveness of claims reviews by complicating provider compliance.
Further differences among the four contractors include:

•        Staffing Requirements: RACs are required to have one full-time employed medical director on their post-payment claims review staff, while CERTs are required to have two medical directors, MACs are required to have three, and ZPICs are required to have one part-time medical director.
•        Limits on Additional Documentation: RACs have limits on the number of additional documents they can request from providers, whereas MACs, ZPICs, and CERTs do not;
•        Minimum Qualifications for Medically Necessary: the minimum qualification for MACs, ZPICs, and CERTs is a licensed practical nurse, while for RACs it is a registered nurse or therapist;
•        Minimum qualifications for Coding Compliance: there is no minimum specified for MACs and ZPICs, while for CERTs and RACs the minimum is a certified coder; and
•        Quality Assurance: MACs, ZPICs, and CERTs do not require external validation of claims by an independent contractor, while RACs do.
The Department of Health and Human Services agreed with all of the recommendations, and said it created a workgroup in 2011 to identify areas of improvement among contractor processes.
To read the full GAO report click here.
The report, was prepared at the request of a bipartisan group of legislators, including Senators Max Baucus (D-Mont.), Orrin Hatch (R-Utah), Tom Carper (D-Del.), Tom Coburn (R-Okla.), Chuck Grassley (R-Iowa), Claire McCaskill (D-Mo.), and Bob Corker (R-Tenn.); and Representatives Fred Upton (R-Mich.), Charles Boustany Jr. (R-La.), John Lewis (D-Ga.), and Diana DeGette (D-Colo.).
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