OIG Releases Study on MAC Performance

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Explore:  CMS MACs Medicare OIG

On January 8, 2014, OIG released a study of Medicare Administrative Contractors’ (MAC) performance between September 2008 and August 2011.  The OIG found that while MACs met the majority of quality assurance standards reviewed by CMS, they did not satisfy all such standards, and the OIG identified other areas for performance improvement. 

The purpose of the OIG’s study was to describe the “extent to which [MACs] met or did not meet performance standards reviewed by CMS” and “to determine the extent to which CMS assessed and monitored MACs’ performance.”  To conduct the study, OIG evaluated thirteen MACs (9 A/B MACs and 4 DME MACs), and reviewed their two most recent performance periods for which the required performance reviews had been completed. 

OIG found that “MACs met the majority of quality assurance standards reviewed by CMS.”  However, OIG also found the following issues:

  • MACs did not meet 26% of all quality assurance standards reviewed by CMS (including failing to meet 51% of provider enrollment standards, 45% of Medicare secondary payer standards, and 43% of appeals process standards);
  • CMS did not always include areas determined to be problematic by quality assurance reviews as metrics in MACs’ award fee plans;
  • MACs had unresolved issues with 27% of unmet standards;
  • CMS failed to require action plans for 12% of unmet standards, which were almost four times more likely to have issues go unresolved;
  • Two MACs consistently underperformed across numerous CMS reviews; and
  • CMS’s performance reviews of MACs were not always completed in a timely manner, running the risk that information gathered by the performance reviews may not be available to evaluate future award decisions.

As a result, OIG recommended that CMS take the following affirmative steps to resolve these outstanding issues:

  • Require action plans for all unmet quality assurance standards;
  • Use quality assurance review results to aid the selection of award fee metrics for review;
  • Meet timeframes for completing quality assurance reports and award fee determinations;
  • Establish sensible timeframes for issuing contractor performance reports; and
  • Seek legislation increasing the time between MAC contract competitions to allow CMS more flexibility in awarding new contracts when MACs do not meet CMS requirements.

CMS concurred with all of OIG’s recommendations.

Reporter, Katy Lucas, Atlanta, +1 404 572 2822, klucas@kslaw.com.

Topics:  CMS, MACs, Medicare, OIG

Published In: Health Updates

DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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