Home Health & Hospice Week

You’ll face more prepayment medical review if the Government Accountability Office gets its way. And it will come from Recovery Audit Contractors.

The GAO examined medical review conducted by Medicare Administrative Contractors, RACs and Supplemental Medical Review Contractors (SMRCs) for a new report, “Claim Review Programs Could Be Improved with Additional Prepayment Reviews and Better Data.”

In 2013 and 2014, 98 percent of MAC claim reviews were prepayment, while 85 percent of RAC claim reviews and 100 percent of SMRC reviews were postpayment, the GAO notes. “Using prepayment reviews to deny improper claims and prevent overpayments is consistent with [the Centers for Medicare & Medicaid Services’] goal to pay claims correctly the first time and can better protect Medicare funds because not all overpayments can be collected,” the GAO says.

Thus, the GAO urges CMS to seek legislation to allow the RACs to conduct more prepayment review. The watchdog agency seems to pick RACs due to their review stats. In 2013 and 2014, RACs had an average cost per review to CMS of $158 and identified $14 in improper payments per dollar paid by CMS to the RACs. In contrast, the SMRC had an average cost per review of $256 and identified $7 in improper payments per dollar paid by CMS. MACs didn’t have reliable enough data to calculate review stats, the GAO notes. And they didn’t perform many reviews on home health claims.

Prior auth: CMS says no thanks to prepay RAC review, however, in its comments responding to the GAO report. MACs, Zone Program Integrity Contractors and Program Safeguard Contractors already conduct prepay review, the agency points out.

And CMS has implemented prior authorization models and increased risk screening to avoid pay-andchase situations, it maintains.

See the report at www.gao.gov/assets/680/676526.pdf.