GAO Issues Report on Post-Payment Claims Reviews by CMS Contractors

by Foley & Lardner LLP

The U.S. Government Accountability Office (GAO) recently issued a report entitled “Medicare Program Integrity: Increased Oversight and Guidance Could Improve Effectiveness and Efficiency of Post-Payment Claims Reviews,” which analyzes the processes used by the Centers for Medicare & Medicaid Services (CMS) to avoid the duplication of post-payment claims reviews by its contractors. GAO’s report focused on the extent to which:

  • CMS has data to assess whether the CMS contractors conduct duplicative post-payment claims reviews and whether CMS ensures that these contractors do so only when appropriate;
  • CMS’ requirements for contractor correspondence with providers help ensure effective communication;
  • CMS uses quality assurance processes to ensure that contractors’ post-payment claims review decisions about whether claims were paid properly are appropriate; and
  • CMS has strategies for coordination of post-payment claims review activities among different types of contractors.

The report follows a similar study undertaken by GAO in July 2013, which recommended that CMS examine the post-payment review requirements for the contractors to evaluate those requirements that could be made more consistent without disrupting efforts to reduce improper payments.

GAO’s report reviewed the post-payment claims review practices of the following four types of CMS claims contractors:

  • The Comprehensive Error Rate Testing (CERT) contractor, which estimates Medicare’s improper payment rate based on its review of claims;
  • Medicare Administrative Contractors (MACs), which process and pay claims;
  • Recover Auditors (RA), which review payments that have been improperly made but not previously reviewed by other contractors; and
  • Zone Program Integrity Contractors (ZPICs), which review claims for potential fraud.

In 2012, RAs conducted 83% of the post-payment claims reviews, while the CERT contractor, MACs, and ZPICs conducted 3%, 6%, and 8% of such reviews, respectively.

In connection with its report, GAO reviewed CMS’ requirements for claims reviews; interviewed CMS officials, certain contractors, and provider associations; analyzed CMS data; evaluated samples of contractor correspondence for compliance with CMS requirements; and evaluated CMS’ requirements and oversight against federal internal control standards. Based on these efforts and information, GAO acknowledged that CMS has implemented a number of measures to guide, oversee, and improve the coordination among its contractors. However, the report concludes that additional efforts by CMS would improve the efficacy and efficiency of the contractors’ claims reviews.

Specifically, GAO indicates that CMS does not have adequate information to estimate the number of duplicative claims reviews performed by its contractors. CMS maintains a Recovery Audit Data Warehouse, which enables the CERT contractor, MACs, and ZPICs to identify and exclude claims that have been reviewed so that the RA will not duplicate a review. However, in some cases, GAO found that the contractors do not consistently log their claims review information. This can result in duplicate post-payment reviews by the RAs. GAO recommends that CMS monitor the Recovery Audit Warehouse to ensure that all post-payment review contractors are submitting required data and that the data the database contains is accurate and complete.

GAO found that CMS has issued clear guidance to RAs and the CERT contractor about whether they may conduct duplicative claims reviews. However, similar guidance has not been issued for the ZPICs and MACs, which may lead to confusion regarding whether duplicative claims reviews by these contractors are permitted in some circumstances. GAO recommends that CMS issue clear guidance regarding which contractors may conduct duplicative claims reviews.

GAO concludes that the contractors sometimes issued inconsistent guidance in their written communications to providers, which may have resulted in providers receiving less information about their responsibilities in responding to the contractor or their rights if their claims were denied. GAO recommends that CMS implement more-consistent requirements and better monitoring of contractors’ compliance with correspondence content requirements.

Lastly, GAO found that CMS does have strategies to coordinate internally regarding its contractors, but GAO suggested that CMS address the different requirements in post-payment claims reviews conducted by the contractors to increase uniformity of approach among the contractors. In particular, GAO notes that increased coordination between ZPICs and RAs is necessary.

The U.S. Department of Health and Human Services reviewed GAO’s report and concurred with GAO’s formal recommendations.

Originally, this article was an alert sent to the American Health Lawyers Association’s (AHLA) Regulation, Accreditation and Payment Practice Group. For more information, visit AHLA’s website.

View This Blog

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.

© Foley & Lardner LLP | Attorney Advertising

Written by:

Foley & Lardner LLP

Foley & Lardner LLP on:

Readers' Choice 2017
Reporters on Deadline

"My best business intelligence, in one easy email…"

Your first step to building a free, personalized, morning email brief covering pertinent authors and topics on JD Supra:
Sign up using*

Already signed up? Log in here

*By using the service, you signify your acceptance of JD Supra's Privacy Policy.
Custom Email Digest
Privacy Policy (Updated: October 8, 2015):

JD Supra provides users with access to its legal industry publishing services (the "Service") through its website (the "Website") as well as through other sources. Our policies with regard to data collection and use of personal information of users of the Service, regardless of the manner in which users access the Service, and visitors to the Website are set forth in this statement ("Policy"). By using the Service, you signify your acceptance of this Policy.

Information Collection and Use by JD Supra

JD Supra collects users' names, companies, titles, e-mail address and industry. JD Supra also tracks the pages that users visit, logs IP addresses and aggregates non-personally identifiable user data and browser type. This data is gathered using cookies and other technologies.

The information and data collected is used to authenticate users and to send notifications relating to the Service, including email alerts to which users have subscribed; to manage the Service and Website, to improve the Service and to customize the user's experience. This information is also provided to the authors of the content to give them insight into their readership and help them to improve their content, so that it is most useful for our users.

JD Supra does not sell, rent or otherwise provide your details to third parties, other than to the authors of the content on JD Supra.

If you prefer not to enable cookies, you may change your browser settings to disable cookies; however, please note that rejecting cookies while visiting the Website may result in certain parts of the Website not operating correctly or as efficiently as if cookies were allowed.

Email Choice/Opt-out

Users who opt in to receive emails may choose to no longer receive e-mail updates and newsletters by selecting the "opt-out of future email" option in the email they receive from JD Supra or in their JD Supra account management screen.


JD Supra takes reasonable precautions to insure that user information is kept private. We restrict access to user information to those individuals who reasonably need access to perform their job functions, such as our third party email service, customer service personnel and technical staff. However, please note that no method of transmitting or storing data is completely secure and we cannot guarantee the security of user information. Unauthorized entry or use, hardware or software failure, and other factors may compromise the security of user information at any time.

If you have reason to believe that your interaction with us is no longer secure, you must immediately notify us of the problem by contacting us at In the unlikely event that we believe that the security of your user information in our possession or control may have been compromised, we may seek to notify you of that development and, if so, will endeavor to do so as promptly as practicable under the circumstances.

Sharing and Disclosure of Information JD Supra Collects

Except as otherwise described in this privacy statement, JD Supra will not disclose personal information to any third party unless we believe that disclosure is necessary to: (1) comply with applicable laws; (2) respond to governmental inquiries or requests; (3) comply with valid legal process; (4) protect the rights, privacy, safety or property of JD Supra, users of the Service, Website visitors or the public; (5) permit us to pursue available remedies or limit the damages that we may sustain; and (6) enforce our Terms & Conditions of Use.

In the event there is a change in the corporate structure of JD Supra such as, but not limited to, merger, consolidation, sale, liquidation or transfer of substantial assets, JD Supra may, in its sole discretion, transfer, sell or assign information collected on and through the Service to one or more affiliated or unaffiliated third parties.

Links to Other Websites

This Website and the Service may contain links to other websites. The operator of such other websites may collect information about you, including through cookies or other technologies. If you are using the Service through the Website and link to another site, you will leave the Website and this Policy will not apply to your use of and activity on those other sites. We encourage you to read the legal notices posted on those sites, including their privacy policies. We shall have no responsibility or liability for your visitation to, and the data collection and use practices of, such other sites. This Policy applies solely to the information collected in connection with your use of this Website and does not apply to any practices conducted offline or in connection with any other websites.

Changes in Our Privacy Policy

We reserve the right to change this Policy at any time. Please refer to the date at the top of this page to determine when this Policy was last revised. Any changes to our privacy policy will become effective upon posting of the revised policy on the Website. By continuing to use the Service or Website following such changes, you will be deemed to have agreed to such changes. If you do not agree with the terms of this Policy, as it may be amended from time to time, in whole or part, please do not continue using the Service or the Website.

Contacting JD Supra

If you have any questions about this privacy statement, the practices of this site, your dealings with this Web site, or if you would like to change any of the information you have provided to us, please contact us at:

- hide
*With LinkedIn, you don't need to create a separate login to manage your free JD Supra account, and we can make suggestions based on your needs and interests. We will not post anything on LinkedIn in your name. Or, sign up using your email address.