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OIG calls on CMS to improve consistency in reviews

OIG calls on CMS to improve consistency in reviews

WASHINGTON - Medicare contractors were inconsistent in how they reviewed overpayments during the appeals process, says the Office of Inspector General in a new report.

Although MACs and QICs generally reviewed appealed extrapolated overpayments in a manner that conforms with existing requirements, CMS did not always provide sufficient guidance and oversight to ensure that these reviews were performed in a consistent manner, the report states.

The most significant inconsistency involved a type of testing that was associated with at least $42 million in extrapolated overpayments that were overturned in 2017 and 2018. If CMS did not intend that the contractors use this testing procedure, these extrapolations should not have been overturned; however, if CMS intended that contractors use this testing procedure, it is possible that other extrapolations should have been overturned but were not.

The OIG recommends that CMS: provide additional guidance to contractors to ensure consistency in procedures; take steps to identify and resolve procedures used to review extrapolations during the appeals process; provide guidance regarding the organization of extrapolation-related files that must be submitted in response to a provider appeal; improve system controls to reduce the risk of contractors incorrectly marking the extrapolation flag field in the Medicare Appeals System; and update the information in the system to accurately reflect extrapolation amounts challenged as part of an appeal.

CMS concurred with the recommendations.


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