CMS Oversight Creates ‘Unnecessary Burden’ for Providers

A government watchdog agency is calling for more oversight from the Centers for Medicare & Medicaid Services (CMS), which may “create an unnecessary burden” on some senior housing providers, a report finds

The U.S. Government Accountability Office (GAO) found that CMS has not been effectively tracking postpayment Medicare claims to ensure the same claim isn’t reviewed multiple times. 

CMS does not have reliable data or sufficient oversight, the GAO says, to measure and fully prevent duplication of postpayment claims reviews, which can determine if a Medicare claim was paid properly or it it was potentially fraudulent.


“Ineffective or inefficient requirements for claims reviews or insufficient monitoring and oversight create the risk of generating false findings of improper payments and an unnecessary administrative and financial burden for Medicare-participating providers and the Medicare program,” the report states. 

The GAO reviewed four types of contractors that examine providers’ documentation to determine whether Medicare’s payment was proper.

These contractors include Medicare Administrative Contractors (MAC), which process and pay claims; Zone Program Integrity Contractors (ZPIC), which investigate potential fraud; Recovery Auditors (RA), which identify on a postpayment basis improper payments not previously reviewed by other contractors; and the Comprehensive Error Rate Testing (CERT) contractor, which reviews claims used to annually estimate Medicare’s improper payment rate.


However, the agency found that CMS has issued inconsistent contractor guidance and requirements, leading to some confusion and review duplication. 

CMS’s “Medicare Program Integrity Manual” states that RAs are prohibited from reviewing claims that have been reviewed by other contractors, but “has not developed guidance” for MACs and ZPICs, and has provided conflicting guidance to CERTs.  

“Our findings in this report indicate that variations in requirements continue to exist. Such variations may result in inefficient processes and present challenges for providers for responding to documentation requests,” the GAO writes. 

To improve Medicare postpayment claims review efforts and simplify compliance for providers, GAO recommends CMS monitor the Recovery Audit Data Warehouse, develop complete guidance to define contractors’ responsibilities, clarify the current requirements and assess regularly whether contractors are complying.

“Because different types of contractors conduct similar claims reviews, CMS guidance, oversight and coordination of them is essential to maintaining an appropriate balance between detecting improper payments effectively and efficiently and avoiding unnecessary administrative burdens,” the GAO writes. “Further actions by CMS could help improve the efficiency and effectiveness of its contractors’ efforts.”

Read the full report here.

Written by Emily Study