GAO to CMS: Your audits fall short

Monday, April 30, 2007

WASHINGTON - CMS and its contractors could do more to address improper payments for durable medical equipment and supplies, according to a report from the General Accountability Office released in early March.
The agency's three Program Safety Contractors (PSCs) use automated prepayment controls or "edits" to deny claims or flag them for medical review, but their efforts fall short in three ways, according to the GAO:
* Contractors don't have automated prepayment controls in place to identify questionable claims that are part of an atypically rapid increase in billing.
* In some instances, contractors don't have controls in place to identify claims for items unlikely to be prescribed in the course of routine quality medical care.
* CMS doesn't require the contractors to share information on the most effective controls of the other contractors or encourage them to adopt other controls.