Medicare Recovery Audit Contracting
Lessons Learned to Address Improper Payments and Improve Contractor Coordination and Oversight
Gao ID: GAO-10-864T July 15, 2010
This testimony discusses preventing and addressing government payment errors in the Medicare program. Medicare, which provides health insurance for those aged 65 and older and certain disabled persons, is susceptible to improper payments due to its size and complexity. Because the Medicare program has paid billions of dollars in error each year, the Centers for Medicare & Medicaid Services (CMS)--the agency that administers Medicare--conducts a number of activities to reduce improper payments. CMS administers the Medicare program with the help of Medicare claims administration contractors, which are not only responsible for processing and paying approximately 4.5 million claims per day, but for also conducting pre-payment reviews of claims to prevent improper payments before claims are paid, as well as post-payment reviews of claims potentially paid in error. To supplement these and other program integrity efforts, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 directed CMS to conduct a 3-year demonstration project on the use of a new type of contractors---recovery audit contractors (RAC)---in identifying underpayments and overpayments, and recouping overpayments in the Medicare program. The RAC demonstration program began in 2005. Subsequently, the Tax Relief and Health Care Act of 2006 required CMS to implement a national recovery audit contractor program by January 1, 2010. Since the conclusion of the demonstration project, CMS and we have reported on improvements needed for the RAC national program. For example, in a June 2008 report evaluating the demonstration project, CMS reported its intent to make a number of changes to the RAC national program to better address RAC-identified vulnerabilities, respond to provider concerns, and streamline operations. In March 2010, we reported on weaknesses in the agency's actions to address improper payments and CMS concurred with our recommendations. The findings in both reports are important in light of the administration's recent commitment to reducing payment errors in federal programs. In addition, the Patient Protection and Affordable Care Act mandates the use of RACs to identify overpayments and underpayments and to recoup overpayments made in Medicare Parts C and D and the Medicaid program. Not only can CMS's experience with RAC contractors benefit its other programs, but lessons learned from the RAC program may also assist other agencies' payment recapture audits, increase the funds recovered, and help prevent such improper payments from being made in the future. Our testimony is based on our March 2010 report13 and will focus on the lessons that can be learned from the RAC demonstration about (1) developing an adequate process and taking corrective action to address RAC-identified vulnerabilities leading to improper payments, (2) resolving coordination issues between the RACs and the Medicare claims administration contractors, and (3) establishing methods to oversee RAC claim review accuracy and provider service during the national program.
Our March 2010 report pointed to three areas for lessons to be learned from the RAC demonstration that could be applicable as CMS expands recovery audits to Medicare Parts C and D and Medicaid and to other agencies' payment recapture efforts. Establishing an effective recovery audit program involves developing processes to take corrective action on underlying vulnerabilities that lead to improper payments; coordinating the activities of various parties that have responsibilities related to the payment process; and assuring recovery audit contractor accuracy and service through oversight. Specifically, agencies should (1) establish an adequate process to address RAC-identified vulnerabilities leading to improper payments. During the demonstration, we found that CMS did not develop a process to take corrective actions or implement sufficient monitoring, oversight, and control activities to ensure the "most significant" RAC-identified vulnerabilities were addressed; (2) Take steps to address coordination issues between contractors. According to CMS, once the RACs identify errors, Medicare claims administration contractors are responsible for re-processing the claims to repay underpayments or recoup overpayments, conducting the first level review for RAC-related appeals, and informing and training providers about lessons learned through the RAC reviews. During the demonstration project, providers noted that RAC determinations resulted in thousands of provider appeals to Medicare claims administration contractors. These appeals and re-processing of claims produced additional workload for the Medicare claims administration contractors, who are also responsible for adjudicating the first level of appeals. The appeals and adjustments workload led to coordination challenges for the Medicare claims administration contractors and RACs. As a result, CMS learned that regular communication between the RACs and the Medicare claims administration contractors regarding RAC-identified payment vulnerabilities was important due to their interdependence; and (3) oversee the accuracy of RACs' claims reviews and the quality of their service to providers. During the demonstration project, providers stated that the contingency fee payment structure CMS employed created an incentive for RACs to be aggressive in determining that paid claims were improper. RACs were paid contingency fees during the demonstration even if their findings were later overturned on appeal. For the national program, CMS changed its payment of contingency fees so that RACs will have to refund contingency fees received on a determination overturned at any level of the appeal process. CMS also established performance metrics that the agency will use to monitor RAC accuracy and service to providers.
GAO-10-864T, Medicare Recovery Audit Contracting: Lessons Learned to Address Improper Payments and Improve Contractor Coordination and Oversight
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Testimony:
Before the Subcommittee on Federal Financial Management, Government
Information, Federal Services, and International Security, Homeland
Security and Governmental Affairs Committee, U.S. Senate:
United States Government Accountability Office:
GAO:
For Release on Delivery:
Expected at 10:00 a.m. EDT:
Thursday, July 15, 2010:
Medicare Recovery Audit Contracting:
Lessons Learned to Address Improper Payments and Improve Contractor
Coordination and Oversight:
Statement of Kathleen M. King, Director:
Health Care:
Statement of Kay L. Daly, Director:
Financial Management and Assurance:
GAO-10-864T:
[End of section]
Mr. Chairman and Members of the Subcommittee:
We are pleased to be here today to discuss preventing and addressing
government payment errors in the Medicare program.[Footnote 1]
Medicare, which provides health insurance for those aged 65 and older
and certain disabled persons, is susceptible to improper payments due
to its size and complexity.[Footnote 2] Because the Medicare program
has paid billions of dollars in error each year,[Footnote 3] the
Centers for Medicare & Medicaid Services (CMS)--the agency that
administers Medicare--conducts a number of activities to reduce
improper payments. CMS administers the Medicare program with the help
of Medicare claims administration contractors,[Footnote 4] which are
not only responsible for processing and paying approximately 4.5
million claims per day, but for also conducting pre-payment reviews of
claims to prevent improper payments before claims are paid, as well as
post-payment reviews of claims potentially paid in error. To
supplement these and other program integrity efforts, the Medicare
Prescription Drug, Improvement, and Modernization Act of 2003 directed
CMS to conduct a 3-year demonstration project on the use of a new type
of contractors---recovery audit contractors[Footnote 5] (RAC)---in
identifying underpayments and overpayments, and recouping overpayments
in the Medicare program.[Footnote 6] The RAC demonstration program
began in 2005. Subsequently, the Tax Relief and Health Care Act of
2006 required CMS to implement a national recovery audit contractor
program by January 1, 2010.[Footnote 7]
Since the conclusion of the demonstration project, CMS and we have
reported on improvements needed for the RAC national program. For
example, in a June 2008 report evaluating the demonstration project,
CMS reported its intent to make a number of changes to the RAC
national program to better address RAC-identified vulnerabilities,
[Footnote 8] respond to provider concerns, and streamline operations.
[Footnote 9] In March 2010, we reported on weaknesses in the agency's
actions to address improper payments and CMS concurred with our
recommendations.[Footnote 10] The findings in both reports are
important in light of the administration's recent commitment to
reducing payment errors in federal programs.[Footnote 11] In addition,
the Patient Protection and Affordable Care Act mandates the use of
RACs to identify overpayments and underpayments and to recoup
overpayments made in Medicare Parts C and D and the Medicaid program.
[Footnote 12] Not only can CMS's experience with RAC contractors
benefit its other programs, but lessons learned from the RAC program
may also assist other agencies' payment recapture audits, increase the
funds recovered, and help prevent such improper payments from being
made in the future.
Our testimony today is based on our March 2010 report[Footnote 13] and
will focus on the lessons that can be learned from the RAC
demonstration about (1) developing an adequate process and taking
corrective action to address RAC-identified vulnerabilities leading to
improper payments, (2) resolving coordination issues between the RACs
and the Medicare claims administration contractors, and (3)
establishing methods to oversee RAC claim review accuracy and provider
service during the national program.
For our March 2010 report, we reviewed CMS documents and interviewed
officials from CMS, as well as contractors and provider groups
affected by the demonstration project. We conducted our work for this
performance audit from March 2009 through March 2010. Our work was
performed in accordance with generally accepted government auditing
standards. Those standards require that we plan and perform the audit
to obtain sufficient, appropriate evidence to provide a reasonable
basis for our findings and conclusions based on our audit objectives.
We believe that the evidence obtained provides a reasonable basis for
our findings and conclusions based on our audit objectives.
Background:
The RAC demonstration project was designed to supplement existing
claims review processes and required the RACs to review claims
previously paid by existing Medicare claims administration
contractors. RACs were charged with identifying payment errors, such
as whether a provider billed the correct number of units for a
particular drug or service. Once a RAC identified a payment error, it
informed the provider of the error and its amount. The Medicare claims
administration contractor then adjusted the claim to the proper
amount[Footnote 14] and collected the overpayment from, or reimbursed
the underpayment to, the provider. CMS paid RACs contingency fees on
overpayments collected and underpayments refunded.[Footnote 15] CMS
and its Medicare claims administration contractors were responsible
for taking corrective actions[Footnote 16] for vulnerabilities
identified by the RACs, including identifying the causes of each type
of vulnerability and addressing them, in order to reduce future
improper payments.
In a 2006 status report, CMS noted that the demonstration RACs
identified $303.5 million in improper payments. However, this amount
did not include the final results of any provider appeals filed
afterwards or pending at that time.[Footnote 17] CMS concluded that
"preliminary results indicate that the use of recovery auditors is a
viable and useful tool for ensuring accurate payments" and that RACs
would be a "value-added adjunct" to the agency's programs. Throughout
the RAC demonstration, CMS stated its intention to use information on
the vulnerabilities found by the RACs to help prevent future improper
payments. In addition, the agency wanted to address concerns expressed
by providers prior to the implementation of a national program, such
as holding the RACs accountable for the accuracy of their decisions.
Lessons Learned Highlight the Need to Develop Processes to Take
Corrective Actions and to Improve Coordination and Oversight:
Our March 2010 report pointed to three areas for lessons to be learned
from the RAC demonstration that could be applicable as CMS expands
recovery audits to Medicare Parts C and D and Medicaid and to other
agencies' payment recapture efforts. Establishing an effective
recovery audit program involves developing processes to take
corrective action on underlying vulnerabilities that lead to improper
payments; coordinating the activities of various parties that have
responsibilities related to the payment process; and assuring recovery
audit contractor accuracy and service through oversight. Specifically,
agencies should:
* Establish an adequate process to address RAC-identified
vulnerabilities leading to improper payments. During the
demonstration, we found that CMS did not develop a process to take
corrective actions or implement sufficient monitoring, oversight, and
control activities to ensure the "most significant" RAC-identified
vulnerabilities were addressed.[Footnote 18] In addition, providers
informed us that CMS did not take corrective actions on RAC-identified
vulnerabilities such as conducting provider education or implementing
computer system edits to help prevent future improper payments. We
found that CMS and the Medicare claims administration contractors did
not implement corrective actions for 35 of 58 (60 percent) of the most
significant vulnerabilities that led to improper payments during the
demonstration as shown in figure 1. We also found that the unaddressed
corrective actions represented $231 million.[Footnote 19]
Figure 1: Status of Corrective Actions for 58 Vulnerabilities with
Improper Payments of Greater Than $1 Million, as of the End of the
Recovery Audit Contractor Demonstration Project--March 2008:
[Refer to PDF for image: pie-chart]
Status of vulnerabilities:
No corrective actions taken: 60% (35):
- Unable to develop corrective actions[A]: 12% (7);
- Corrective actions not taken: 48% (28).
Corrective actions taken: 40% (23):
- Edits implemented: 12% (7);
- Education provided 10% (6);
- Clarification of guidance/issuance of new regulations: 17% (10).
Source: GAO analysis of CMS data.
[A] According to CMS officials the agency was unable to develop
corrective actions because it either lacked adequate information on
the specific services involved or decided it was not cost effective to
do so.
Note: Potential corrective actions include implementing computer edits
that deny improper claims or flag claims for further review, educating
providers about Medicare rules and proper billing procedures and
issuing clarification of guidance or a new regulation.
Percentages in figure may not add to 100 due to rounding.
[End of figure]
For the four RAC contractors implementing the national program, CMS
developed a process to compile identified vulnerabilities and
recommend actions to prevent improper payments. However, we found that
this new corrective action process lacked essential procedures, such
as evaluating the effectiveness of corrective actions taken, and staff
with the authority to ensure that these vulnerabilities are resolved
promptly and adequately to prevent further improper payments. Our
report recommended that the Administrator of CMS develop and implement
a process that includes policies and procedures to ensure that the
agency promptly evaluates findings of RAC audits, decides on the
appropriate response and a time frame for taking action based on
established criteria, and acts to correct the vulnerabilities
identified. As part of this process, we recommended that the
Administrator of CMS designate key personnel with appropriate
authority to be responsible for ensuring that corrective actions are
implemented and that the actions taken are effective. In commenting on
a draft of the report, CMS concurred with our recommendations and
stated that the Administrator of CMS is the official responsible for
assuring that vulnerabilities that cut across all agency components
are addressed.
* Take steps to address coordination issues between contractors. The
agency continued activities that worked well during the demonstration
project, initiated a number of new actions, and is taking steps to
address coordination challenges. According to CMS, once the RACs
identify errors, Medicare claims administration contractors are
responsible for re-processing the claims to repay underpayments or
recoup overpayments, conducting the first level review for RAC-related
appeals, and informing and training providers about lessons learned
through the RAC reviews. During the demonstration project, providers
noted that RAC determinations resulted in thousands of provider
appeals to Medicare claims administration contractors. These appeals
and re-processing of claims produced additional workload for the
Medicare claims administration contractors, who are also responsible
for adjudicating the first level of appeals. The appeals and
adjustments workload led to coordination challenges for the Medicare
claims administration contractors and RACs. As a result, CMS learned
that regular communication between the RACs and the Medicare claims
administration contractors regarding RAC-identified payment
vulnerabilities was important due to their interdependence. In
addition, CMS created a data warehouse for the demonstration that
contained information on which claims were unavailable for RAC review
to prevent the RACs from auditing claims previously reviewed by a
claims administration contractor or other contractor investigating
potential Medicare fraud. For the national program, CMS modified the
data warehouse to include more capacity and utility. The agency also
automated the manual claims adjustment process used by the Medicare
claims administration contractors to recoup improper payments in order
to reduce their administrative burden. Further, the volume of provider
appeals made it difficult to manage all of the paper medical records
that needed to be exchanged between the RACs and claims administration
contractors in order to assess the RAC determinations. Provider
association and hospital representatives noted the RACs sometimes
requested duplicate medical records to evaluate the medical necessity
or appropriateness claims as part of their reviews, thus increasing
providers' administrative burden. As a result, CMS developed an
electronic documentation sharing system to improve storage and
transfer of medical records.
* Oversee the accuracy of RACs' claims reviews and the quality of
their service to providers. During the demonstration project,
providers stated that the contingency fee payment structure CMS
employed created an incentive for RACs to be aggressive in determining
that paid claims were improper. RACs were paid contingency fees during
the demonstration even if their findings were later overturned on
appeal. For the national program, CMS changed its payment of
contingency fees so that RACs will have to refund contingency fees
received on a determination overturned at any level of the appeal
process. CMS also established performance metrics that the agency will
use to monitor RAC accuracy and service to providers. In addition, CMS
added processes to review the accuracy of RAC determinations including
independent reviews by a validation contractor. Prior to pursuing a
wide-scale review of any vulnerability in the national program, the
RAC must submit information and a small sample of reviewed claims and
related findings to CMS to check for accuracy and to ensure the RAC's
compliance with the rule, policy, or regulation against which the
claims will be evaluated. CMS has also established a process for
ongoing oversight of RAC accuracy through a regular independent
assessment of a sample of RAC-reviewed claims and determinations by
the validation contractor. This will lead to an annual accuracy score
for each RAC, scores which CMS intends to publish. Further, CMS
established requirements to address provider concerns about service.
Specifically, CMS required RACs to establish Web sites that will allow
providers to track the status of a claim being reviewed and include
information on each vulnerability being audited by that RAC. However,
because the agency does not have a standard system to track appeals
through the entire five levels of the appeals process, CMS does not
require RACs to provide information on the status of claims' appeals
on their Web sites.
In conclusion, the ultimate success of the government-wide effort to
reduce improper payments hinges on each federal agency's diligence and
commitment to identify, estimate, determine the causes of, take
corrective actions on, and measure progress in reducing improper
payments. CMS's experience provides useful lessons for the management
of the Medicare and Medicaid programs, as well as other recovery
auditing programs on the importance of addressing the root causes of
vulnerabilities to improper payments and effectively coordinating and
overseeing the accuracy of contractors. Such lessons may be useful as
recovery auditing is incorporated more broadly in the federal
government.
Mr. Chairman, this concludes our prepared statement. We would be happy
to answer any questions you or other members of the subcommittee may
have.
GAO Contacts and Staff Acknowledgments:
For further information about this statement, please contact Kathleen
M. King at (202) 512-7114 or kingk@gao.gov or Kay L. Daly, (202) 512-
9095 or dalykl@gao.gov.
Sheila Avruch and Carla Lewis, Assistant Directors; Jennie F. Apter;
Anne Hopewell; Laurie Pachter; Nina M. Rostro; and James Walker were
key contributors to this statement.
[End of section]
Footnotes:
[1] Medicare consists of four parts. Medicare Fee for Service (FFS)
includes two parts--Medicare Parts A and B whereby providers are paid
for each service, unit or bundle of services provided. Medicare Part A
covers inpatient hospital services, skilled nursing facility services,
some home health, and hospice services. Medicare Part B covers
hospital outpatient, physician services, some home health services and
preventive services, among other things. Medicare beneficiaries have
the option of obtaining coverage for Medicare Part A and B services
from private health plans that participate in Medicare Advantage--
Medicare's managed care program, also known as Medicare Part C. All
Medicare beneficiaries may purchase coverage for outpatient
prescription drugs under Medicare Part D.
[2] Improper payments may be due to errors, such as the inadvertent
submission of duplicate claims for the same service, or misconduct,
such as fraud and abuse. Fraud is an intentional act or representation
to deceive with knowledge that the action or representation could
result in an inappropriate gain. Abuse typically involves actions that
are inconsistent with acceptable business or medical practices and
result in unnecessary costs.
[3] For example, in 2009 the Department of Health and Human Services
(HHS) estimated that approximately $24.1 billion or 7.8 percent of
Medicare FFS payments for claims from April 2008 through March 2009
were improper. (November 2009 "Improper Medicare FFS Payments Report"
in HHS's Fiscal Year 2009 Agency Financial Report.) Since 1990,
Medicare has been included in our reporting of "high risk" areas,
those government operations involving substantial resources and that
provide critical services to the public that we find to contain
serious weaknesses. See GAO, High-Risk Series: An Update, GAO-09-271
(Washington, D.C.: January 2009) and [hyperlink,
http://www.gao.gov/highrisk/risks/insurance/medicare_program.php].
[4] CMS has historically used contractors, known as fiscal
intermediaries and carriers, to process Medicare claims. CMS is in the
process of transitioning to new contracting entities called Medicare
Administrative Contractors. Because the transition is ongoing, we use
the term Medicare claims administration contractors to refer to the
contractors that historically have processed Medicare claims as well
as the new Medicare Administrative Contractors.
[5] Recovery auditing has been used in various industries, including
health care, to identify and collect overpayments for about 40 years.
[6] Pub. L. No. 108-173, § 306, 117 Stat. 2066, 2256-57.
[7] Pub. L. No. 109-432, div B., title III, § 302, 120 Stat. 2922,
2991-92 (codified at 42 U.S.C. § 1395 ddd(h)).
[8] A vulnerability is an issue likely to lead to an improper payment
such as billing the incorrect number of units for a particular drug or
service or inpatient hospital claims not meeting CMS's criteria for
inpatient admission.
[9] See Department of Health and Human Services, Centers for Medicare
and Medicaid Services, The Medicare Recovery Audit Contractor (RAC)
Program: An Evaluation of the 3-Year Demonstration (Baltimore, Md.:
June 2008).
[10] See GAO, Medicare Recovery Audit Contracting: Weaknesses Remain
in Addressing Vulnerabilities to Improper Payments, Although
Improvements Made to Contractor Oversight, GAO-10-143 (Washington,
D.C.: March 31, 2010).
[11] Finding and Recapturing Improper Payments, 75 Fed. Reg. 12,119
(March 15, 2010); See also Exec. Order No. 13,520, 74 Fed. Reg. 62,201
(Nov. 25, 2009); & OMB Circular No. A-123, Appx. C, Requirements for
Effective Measurement and Remediation of Improper Payments (Revised
March 22, 2010).
[12] Pub. L. No. 111-148, § 6411, 124 Stat. 119, codified at 42 U.S.C.
§§ 1396a(a)(42)(B) and 1395ddd(h).
[13] See [hyperlink, http://www.gao.gov/products/GAO-10-143].
[14] During the demonstration project, the Medicare claims
administration contractors processed hundreds of thousands of RAC
claim adjustments--some manually--which created significant additional
workload.
[15] During the demonstration, CMS paid the RACs a total of $187.2
million in contingency fees. Initially, the RAC demonstration project
did not include contingency fee payment to the RACs for identifying
underpayments and refunding providers. Beginning on March 1, 2006, the
RACs were paid an equivalent percentage contingency fee for the
identification of underpayments.
[16] Corrective actions that could be taken by CMS or its Medicare
claims administration contractors include: conducting provider
outreach and education; developing guidance or new regulations;
reissuing instructions for coding a claim or initiating additional
service-specific local or national prepayment computer edits to deny
improper claims or flag them for additional review.
[17] Providers could appeal unfavorable RAC determinations through the
standard Medicare appeals process, which includes five levels of
review. The Medicare claims administration contractors conduct the
first level of appeal.
[18] According to CMS, the most significant vulnerabilities were those
for which RACs identified more than $1 million in improper payments
for medical services or $500,000 for durable medical equipment.
[19] These unaddressed vulnerabilities are a portion of 18 specific
medical services CMS valued at $378 million.
[End of section]
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