The Centers for Medicare and Medicaid Services does not have reliable data nor provides sufficient oversight to measure and prevent payment contractors--particularly Recovery Audit Contractors--from conducting certain duplicative post-payment claims reviews.

That is the conclusion of a new Government Accountability Office report on the Medicare contractor post-payment claims review process. In the case of Recovery Audit Contractors, tasked with identifying improper payments not previously reviewed by other contractors, CMS implemented a database to track RAC activities--designed in part to prevent RACs, which conducted most of the post-payment reviews, from duplicating other contractors' reviews.

However, GAO found that the database--the Recovery Audit Data Warehouse--was not designed to provide information on all possible duplication, and its data are not reliable because other post-payment contractors did not consistently enter information about their reviews. As a result, the Recovery Audit Data Warehouse’s information on excluded claims is sometimes inaccurate and its effectiveness in preventing the RACs from conducting inappropriate duplicative claims reviews is limited, auditors concluded.

“CMS has not provided sufficient oversight of these data or issued complete guidance to contractors on avoiding duplicative claims reviews,” states the report.

GAO recommended that CMS take actions to improve the efficiency and effectiveness of contractors' post-payment review efforts, including monitoring the Recovery Audit Data Warehouse to ensure that all Medicare post-payment review contractors are submitting required data. In its comments, the Department of Health and Human Services concurred with the recommendations and noted plans to improve CMS oversight and guidance.  

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