Key Issues > Duplication & Cost Savings > GAO's Action Tracker > Medicare Postpayment Claims Reviews (2015-07)
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Health: Medicare Postpayment Claims Reviews (2015-07)

To prevent inappropriate duplicative postpayment claims reviews by contractors, the Centers for Medicare & Medicaid Services should monitor the Recovery Audit Data Warehouse—the database developed in part to prevent duplicative reviews—and develop more complete guidance on contractors' responsibilities.

Action:

In order to improve the efficiency and effectiveness of Medicare postpayment claims review efforts and to prevent inappropriate duplicative claims reviews among Medicare contractors, the Administrator of the Centers for Medicare & Medicaid Services (CMS) should monitor the Recovery Audit Data Warehouse to ensure that all postpayment review contractors are submitting required data and that the data the database contains are accurate and complete.

Progress:

As of December 2018, CMS had taken steps to monitor the Recovery Audit Data Warehouse to ensure that all contractors are submitting required data and that the data they submit are accurate and complete, as GAO recommended in July 2014.

CMS took three key steps between 2015 and 2017, which included the following: (1) allowing more time for Medicare Administrative Contractors (MAC) to enter complete claims review information into the Recovery Audit Data Warehouse to prevent Recovery Auditors from re-reviewing the claims reviewed by MACs, (2) implementing a new process to monitor the data that contractors enter into the Recovery Audit Data Warehouse, and (3) periodically verifying that MACs submit all required data to the Warehouse.

By taking these steps to improve its oversight of the Recovery Audit Data Warehouse, CMS has helped ensure that Medicare contractors conduct efficient postpayment claims reviews and avoid inappropriate duplication.

Implementing Entity:

Centers for Medicare & Medicaid Services

Action:

In order to improve the efficiency and effectiveness of Medicare postpayment claims review efforts and to prevent inappropriate duplicative claims reviews among Medicare contractors, the Administrator of the Centers for Medicare & Medicaid Services (CMS) should develop complete guidance to define contractors’ responsibilities regarding duplicative claims reviews, including specifying whether and when Medicare Administrative Contractors (MAC) and Zone Program Integrity Contractors (ZPIC) can duplicate other contractors’ reviews.

Progress:

CMS has developed complete guidance to define contractors’ responsibilities regarding duplicative claims reviews, as GAO recommended in July 2014. In September 2016, CMS updated its Medicare Program Integrity Manual to provide complete guidance regarding whether contractors, specifically Medicare Administrative Contractors and Zone Program Integrity Contractors, may conduct duplicative reviews. According to CMS's updated guidance, which took effect November 4, 2016, Medicare Administrative Contractors are not permitted to review any claim previously reviewed by another contractor. Zone Program Integrity Contractors are permitted to review a claim previously reviewed by another contractor to support their case development or other administrative action. This guidance should help prevent inappropriate duplicative claims reviews. 

Implementing Entity:

Centers for Medicare & Medicaid Services
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    • Jessica Farb
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