Home Health & Hospice Week

Response timeframes to ADRs may tighten up under GAO recommendation.

It may seem like you are bombarded with record requests for medical review, but the Medicare program is still reviewing a tiny portion of the claims it pays.

The Centers for Medicare & Medicaid Services has four contractors that conduct claims review — Medicare Administrative Contractors (MACs), Zone Program Integrity Contractors (ZPICs), Recovery Audit Contractors (RACs), and the Comp-rehensive Error Rate Testing (CERT) contractor, the Government Accountability Office says in a new report. "Medicare Program Integrity: Increasing Con-sistency of Contractor Requirements May Improve Administrative Efficiency."

"Compared to over 1 billion claims pro-cessed in 2012, all four types of contractors combined reviewed less than one 1 percent of claims, about 1.4 million reviews, for which providers might be contacted to send in medical records or other documentation," the GAO says in a summary of the report.

Differences in review requirements for the four types of contractors "may impede efficiency and effectiveness of claims reviews by increasing administrative burden for providers," the GAO says in a summary of its report. "There are differences in oversight of claims selection, time frames for providers to send in documentation, communications to providers about the reviews, reviewer staffing, and processes to ensure the quality of claims reviews."

For example: "While the CERT contractor must give a provider 75 days to respond to a request for documentation … the ZPIC is only required to give the provider 30 days," the GAO notes.

Bottom line: "Having inefficient processes that complicate compliance can reduce effectiveness of claims reviews," GAO says.

The Department of Health and Human Services already is looking at standardizing the minimum number of days providers have to respond to ADRs, HHS Assistant Secretary for Legislation Jim Esquea says in the Department’s response to the report. Standardizing that number "could help minimize provider confusion," Esquea allows.

HHS will take steps to reduce differences in medical review elsewhere as well, the agency pledges.

Resource: A link to the report is at www.gao.gov/products/GAO-13-522.