Only CERTs and ZPICs can duplicate postpayment audits, CMS says

by: Laura Evans Sep 8, 2016

Here’s something that could help cut down the volume of duplicate Medicare audits coming into your practice.

In response to a July 2014 Government Accountability Office (GAO) report that pointed out CMS hasn’t been doing a good job preventing duplicate post-payment reviews by its contractors; the Medicare agency is at last taking steps to fix the problem.

First up, CMS added a few lines to its Medicare program integrity manual (CMS pub 100-08, Chapter 3) to clarify that the following contractors “shall not perform a duplicate review for any claim previously reviewed by another contractor:” Medicare administrative contractors (MACs), supplemental medical review contractors (SMRCs) and recovery auditors (RAs), according to CMS Transmittal 674, dated Sept. 2.

CMS made a couple of exceptions to the policy, which takes effect Nov. 4:

Comprehensive error rate testing (CERT) contractors may duplicate another contractor’s review “when appropriate, if those claims are chosen as part of a statistically valid random sample to measure the improper payment rate,” the transmittal states.
Zone program integrity contractors (ZPICs), which investigate possible fraud cases, also can continue to review “a claim that has been reviewed by another contractor in order to support their case development or other administrative action,” CMS added.

CMS tracks contractor audit activity in an RA audit database where MACs, ZPICs and the CERT contractor can enter the claims they have reviewed. Database claims then are labeled “excluded” to keep the RAs from again reviewing those claims, according to the GAO report.

However, CMS doesn’t keep careful track of whether those contractors consistently enter claims into the database (GAO found that they are not), or whether duplicate audits are occurring (they most likely are), GAO stated.

Further, GAO found that the policy manual was incomplete at best on whether the various audit contractors could perform duplicate audits. Transmittal 674 would appear to check that one off the list, at least. It remains to be seen how CMS will address GAO’s other recommendations, such as monitoring its RA database to make sure audit contractors are entering required data and making sure those contractors are complying with the rules about correspondence with providers.

Blog Tags: CMS, RACs

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