Council for Medicare Integrity urges CMS to implement prepayment claim reviews in fee-for-service program

The Council for Medicare Integrity, a nonprofit advocacy organization, is calling on CMS to implement prepayment claim reviews within Medicare Parts A and B. CMS included such reviews for Medicare Advantage and Part D in its 2019 Medicare Inpatient Prospective Payment System proposed rule filed April 24.

The rule, which applies to about 3,300 acute care hospitals and 420 long-term care hospitals, incentivizes managed care organizations to review claims prior to payment for billing accuracy, rather than relying on “pay and chase” efforts to combat improper payments and fraud, according to CMI.

In April, CMS wrote “fraud reduction activities can lower the cost of care and reduce trust fund expenditures and thereby potentially provide value to beneficiaries, the government and taxpayers.”

Now, CMI is calling on CMS to implement prepayment claim reviews within Medicare Parts A and B as well.

In a news release, CMI officials specifically point to the three-year Prepayment Review Demonstration project CMS launched in fiscal year 2012. They said the program, which allowed recovery audit contractors to review certain Medicare fee-for-service claims prior to payment, resulted in RACs preventing approximately $200 million in improper payments.

Overall, CMI officials contend new RAC prepayment reviews in the Medicare fee-for-service program would help ensure proper reimbursement.

“Medicare fraud and waste are absolutely patient safety and quality of care issues,” said CMI spokesperson Kristin Walter. “We ask CMS to apply the same important philosophy implemented within Medicare Advantage and Medicare Part D to similarly add prepayment claim reviews to benefit Medicare FFS program.”

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