Congress Requests Review of Medicare Oversight Efforts

Members of the Senate Finance, the House Energy and Commerce and the House Ways and Means Committees – those with jurisdiction over Medicare in the United States Congress and with responsibility for oversight of the Centers for Medicare & Medicaid Services (CMS) and the federal health care programs administered by CMS have requested that the Government Accountability Office (GAO) conduct a study regarding coordination of the various audits that are being conducted in the Medicare program.

The Medicare fee-for-service program is overseen by a number of different contractors, including the Medicare Administrative Contractors (MACs), the Medicare Recovery Audit Contractors (RACs), the Zone Program Integrity (ZPICs) and Program Safeguard Contractors (PSCs), and the CERT (Comprehensive Error Rate Testing Review) Contractor, each with its own particular responsibilities to ensure that Medicare pays claims accurately in accordance with Medicare law and policy.

As requested by the three congressional committees, the GAO will undertake a study that focuses on coordination among contractor efforts and CMS efforts to oversee these contractors to ensure that they are working efficiently and effectively while guaranteeing that beneficiaries are receiving care to which they are entitled.

Specifically, the GAO request asks that the agency evaluate the following questions:

  1. What process does CMS use to determine whether the contractors' audit criteria and methodologies are valid, clear and consistent?
  2. How does CMS coordinate among these contractors to ensure that their interactions with providers are not duplicative? Is there any evidence of providers being subjected to multiple overlapping audits on the same topic? If so, how frequently does this occur? Is there any justification for a single provider being audited by multiple contractors at the same time?
  3. What are the reasons for requesting that similar information be submitted to multiple contractors? Are there steps CMS is taking to limit duplicative audits, while still ensuring contractors have the tools necessary to pursue program integrity efforts?
  4. Does CMS have a strategic plan to coordinate and oversee all of its audit activities and, if so, how is that plan implemented and overseen?