CHA News Article

GAO Releases Study on Oversight of Efforts to Reduce Improper Billing

Earlier this week, the U.S. Government Accountability Office (GAO) released a report examining Medicare administrative contractor (MAC) provider education departments’ efforts to reduce improper payments in the Medicare fee-for-service program. To help ensure payments are made properly, the Centers for Medicare & Medicaid Services (CMS) contracts with MACs to conduct provider education efforts. However, for fiscal year 2016, the Department of Health and Human Services reported an estimated 11 percent improper payment rate and $41.1 billion in improper payments. The GAO’s report examines the efforts made to reduce improper payments, CMS’ oversight of these efforts and the extent to which the efforts were effective.

According to the GAO, CMS collects limited information about areas particularly vulnerable to improper billing and has not required MACs to provide specifics on the areas addressed by their provider education departments. In addition, CMS does not require MACs to educate providers who refer patients for durable medical equipment or home health services on proper billing documentation — but this area comprises a large portion of improper payment rates due to insufficient documentation.

The GAO recommends that CMS require additional detail to determine the extent to which a MAC’s provider education department focuses on vulnerable areas, mandate that MACs work together to educate referring providers on proper documentation for durable medical equipment and home health services, and establish performance metrics for further reviews.