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Friday, August 23, 2013

Are Medicare Contractor Reviews Too Confusing?

by James Swann

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Differing standards and requirements among four Medicare program integrity contractors are leading to some major headaches for providers and reducing the overall efficiency of postpayment claims reviews, GAO said in a recent report. The problem, according to the report, is that the four contractors were all created under different laws, resulting in a lack of consistency in their postpayment claims review processes.

For example, Zone Program Integrity Contractors (ZPICs) give providers 30 days to respond to a request for additional documentation on a reviewed claim before deeming it improper, compared to the 75 days given to providers by Comprehensive Error Rate Testing (CERTs), the GAO said. Medicare Administrative Contractors (MACs) and Recovery Audit Contractors (RACs) give providers 45 days to respond.

GAO recommended that CMS re-evaluate postpayment review processes for the four contractors. "Greater consistency in the claims review requirements across contractors may improve the efficiency of postpayment reviews by strengthening the control environment, lessening providers' confusion, and reducing administrative burdens," the report said.
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