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GAO: CMS Should Bolster Guidance of Postpayment Claims Review Process

GAOA Government Accountability Office report on contractors that examine postpayment claims for the Centers for Medicare and Medicaid Services recommends CMS establish stronger oversight and guidance on the process to avoid duplication.

GAO said in that report, issued Monday, that CMS should ensure that Medicare administrative contractors, zone program integrity contractors, recovery auditors and the contractor for comprehensive error rate testing do not repeat reviews of improper payments.

Eliminating duplicative claims reviews through improved data management, coordination and contractor-provider correspondence would facilitate efficiency and effectiveness in the claims review process, GAO said.

GAO says the database CMS uses to track review activities is not comprehensive because it is not used consistently by all contractor types and the required content of correspondence between contractors and healthcare providers is not standardized, with contractor compliance varying.

Auditors also said there is no full coordination between RAs and ZPICs despite CMS-implemented methods to facilitate inter-contractor coordination.

GAO said it recommends the Department of Health and Human Services help CMS to monitor data entry into the Recovery Audit Data Warehouse, establish guidance on contractor responsibilities, conduct regular assessment of contractor compliance and clarify the correspondence requirements.

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