Audits: GAO weighs in on duplicative reviews

Friday, August 15, 2014

WASHINGTON – The Government Accountability Office (GAO) is calling on CMS to improve the efficiency and effectiveness of its post-payment review efforts by providing contractors with additional guidance and more oversight.

The GAO reviewed MACs, ZPICs, RAs and CERT contractors because “questions have been raised about their effectiveness and efficiency, and the burden on providers.” 

While CMS has taken steps to prevent contractors from conducting duplicative post-payment claims reviews, the GAO found, “CMS neither has reliable data nor provides sufficient oversight and guidance to measure and fully prevent duplication.”

Specifically, the GAO report called on CMS to:

• monitor the Recovery Audit Data Warehouse to ensure contractors are submitting required data and that the data in the database are accurate and complete;

• develop complete guidance defining contractors’ responsibilities regarding duplicative claims reviews, including specifying whether and when MACs and ZPICs can duplicate other contractors’ reviews;

• regularly assess whether contractors are complying with CMS requirements for the content of correspondence sent to providers; and

• clarify current requirements for content of additional documentation requests and results letters, and standardize the requirements as much as possible for greater consistency.

The Department of Health and Human Services agreed with the GAO’s recommendations and noted plans to improve CMS guidance and oversight.