Advocacy group calls on CMS to increase Medicare audits, expand review criteria


The Council for Medicare Integrity this week asked Department of Health & Human Services Secretary Alex Azar to expand efforts to reduce improper Medicare billing as heading off some planned program cuts.

While praising the secretary’s previous compliance efforts, a letter from the Council urges him to bolster program integrity efforts at the Centers for Medicare & Medicaid Services and save money by expanding the use of existing tools.

“Since Congress mandated the RAC Program, more than $10 billion in improper payments have been returned to the Medicare Trust Fund and more than $800 million in underpayments have been paid out to providers — balancing Medicare’s checkbook and ultimately, extending the life of the program by two full years,” wrote Kristin Walter, a spokesperson for the Council. “We urge you to consider how a focused effort to reduce Medicare waste could be the low-hanging fruit that could infuse nearly $40 billion back into your budget each year and ensure consistent future coverage for beneficiaries.”

Regulatory review and shrinking payments will be a topic of focus at next week’s McKnight’s Online Expo. Presenter Leah Klusch, RN, BSN, FAHCA, the founder of The Alliance Training Center, will host a March 14 session on operational strategies for surviving these uncertain times — when regulatory, payment and data-reporting standards are in near-constant flux.

The Council issued its letter as the skilled nursing providers faces a freeze in their share of “market basket” funding and long-term budget cuts totaling about $1.9 billion.

Walter said one way to curtail the need for those cuts is to take a closer look at the traditional Medicare Fee for Service program, where just 0.5% of provider claims can be reviewed for accuracy, allowing most claims to be paid without ensuring they accurately reflect the care provided.

Walter said that lack of oversight has caused the program to unnecessarily spend more than $200 billion over the past five years alone. That “would never be allowed to occur in the private sector, where a healthy bottom line determines the policy,” she wrote.

In addition to asking for an overall increase in audits, the Council also supports widening the scenarios that can trigger a review and bringing back a prepayment review process demonstrated in 11 states between 2012 and 2014.

The program saved Medicare $192 million, but despite recommendations from the Government Accountability Office, it was never made permanent.

“The combination of higher post-payment reviews with a new prepayment review program will go far to help close the loophole that’s permitted the program to overspend by more than $200 billion over the last five years,” Walter wrote.

Read more here.

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