Consistent Contractor Requirements Would Lessen Load For Providers

By Greg Bengel, contributing writer

The GAO calls on CMS to make requirements for different Medicare contractors more consistent in order to improve claim efficiency and lessen administrative burden for providers

A recent report from the Government Accountability Office (GAO) urges CMS to make its requirements for Medicare contractors more consistent. Doing so, they say, would not only make post-payment claims more efficient, it would also lessen the administrative burden contractors are placing on healthcare providers.

Medicare contractors have been a major nuisance for healthcare providers of late. For instance, Recovery Audit Contractors, who have recovered millions in improper Medicare payments, have displayed aggression that has resulted in the denial of many valid claims. As previously reported, this burdens legitimate hospitals and physicians.  Also, one provider recently testified that RACs are supposed to focus on underpayments as well as overpayments, but underpayments are rarely found. 

The GAO report looks at the burden imposed by RACs and other contractors. An article from Becker’s Hospital Review summarizes the report. The article explains that there are four different types of contractors reviewing Medicare claims. One type is RACs, already mentioned. Also, there are Medicare Administrative Contractors, who work directly with claims to prevent payment errors; Zone Program Integrity Contractors, who investigate potential fraud within a designated geographic area; and Comprehensive Error Rate Testing contractors, who look at samples of claims and other documents to measure nationwide improper payment rates for claims. 

Becker’s Hospital Review says, “All of these contractors use the same general post-payment claims review process, but CMS has different requirements for the review procedure depending on the type of contractor, according to the GAO. For example, CERT contractors must give providers 75 days to respond for requests for documentation before the contractors can declare a claim improper because of a lack of documentation. ZPIC entities only have to give providers 30 days to respond.”

According to the GAO, these differing requirements reduce effectiveness and increase the clerical headaches for providers. The GAO’s suggestion is that CMS “examine its claims review requirements for contractors and determine how to make them more consistent. CMS should then announce its findings and its plan for taking action. The agency should work to eliminate differences in a way that doesn't interfere with improper payment reduction efforts,” reports the Becker’s Hospital Review article.