GAO Concludes CMS Should Increase Oversight of Post-Payment Claims Review Process


The Government Accountability Office (GAO) has released the findings of its study of the steps taken by CMS to prevent Medicare contractors from conducting certain duplicative post-payment claims reviews. Based on its audit, the GAO has recommended that CMS take actions to improve the efficiency and effectiveness of its contractors’ post-payment review efforts, including providing additional oversight and guidance regarding duplicative reviews.

In assessing post-payment claims reviews conducted by Medicare Administrative Contractors (MACs), Zone Program Integrity Contractors (ZPICs), Recovery Audit Contractors (RACs), and the Comprehensive Error Rate Testing (CERT) contractor, the GAO evaluated: (1) the extent to which CMS has data to determine if the contractors conduct duplicative post-payment claims reviews and whether CMS ensures that the contractors do so only as necessary; (2) whether CMS’s requirements for contractor communication with providers are effective and consistent; (3) the extent to which CMS conducts quality reviews of the contractors’ decisions about whether claims were paid properly; and (4) the extent of CMS’s methods to coordinate the contractors’ claims review process.

In its study, the GAO evaluated the effectiveness of the Recovery Audit Data Warehouse, a tool created by CMS intended to assist RACs, which perform most of the reviews, to avoid duplicating reviews performed by other contractors. However, the GAO noted that the Data Warehouse has limitations, including that it was not designed to estimate duplicative reviews performed by the other contractors, which limits the available data on duplicative reviews, and that not all contractors have been entering information into the Data Warehouse consistently, which reduces its effectiveness. Further, CMS has only issued guidance for some contractors regarding when duplicative reviews are appropriate. The GAO also noted that contractors’ correspondence with providers in connection with post-payment claims examination often differs by contractor and may not always comply with all of CMS’s requirements for such communications. Further, while CMS has methods to coordinate contractors’ claims review activities, such as requiring joint operating agreements for MACs, RACs, and ZPICs operating in the same jurisdictions, the review process among the contractors still is not consistent.

The GAO concluded that while CMS has established a number of mechanisms to ensure the effectiveness and efficiency of the post-payment claims review process, certain additional actions by CMS would help improve the process, including the following: (1) issuing guidance for all contractors on when duplicative review is appropriate; (2) ensuring accurate data entry into the Data Warehouse; (3) better monitoring and guidance of contractor communication to providers; and (4) ensuring appropriate coordination and communication among the contractors. HHS concurred with the GAO’s recommendations in the report and discussed its plans to address the GAO’s recommendations. A summary of the report may be found here.

Reporter, Christina A. Gonzalez, Houston, +1 713 276 7340,

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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