Medicare Compliance & Reimbursement

Although the OIG's recent report elucidates the Feds' interest in recovering improper payments, it's important  to note that the government doesn't just hunt down inappropriately paid claims -- it also pinpoints the hurdles that it faces.

On June 15, Kathleen King, director of health care in the Government Accountability Office (GAO), offered testimony before Congress in which she profiled the challenges and strategies for preventing improper payments, culminating in the following five areas of interest, according to King's testimony:

1. Strengthening provider enrollment process and standards. King recommended that checking the background of providers when they apply for Medicare provider status can reduce the risk of enrolling potentially fraudulent providers.

2. Improving pre-payment claims reviews. To ensure that Medicare pays claims correctly the first time, the GAO recommends that CMS "further enhance its ability to identify improper claims through additional automated pre-payment claim review" before they're paid.

3. Focusing post-payment reviews on the most vulnerable areas. If CMS targets claims for postpayment reviews on the most at-risk areas, the GAO believes that payment errors and overpayment recoupment can be better streamlined.

4. Improving contractor oversight. CMS should expand its oversight of Medicare contractors (the MACs), which are the entities that process the claims.

5. Developing a "robust process" for addressing identified vulnerabilities. CMS should specifically address mechanisms to resolve vulnerabilities that lead to improper payments so that issues can be quickly resolved.

(Editor's note: Visit www.gao.gov/new.items/d10844t.pdf for the complete GAO report, and www.gao.gov/highlights/d10844thigh.pdf for the report highlights.)