GAO: CMS must assess, strengthen documentation requirements and medical reviews to address $23 billion in improper payments

April 3, 2019
Medicare Web

Insufficient documentation led to approximately $23 billion in improper Medicare payments in fiscal year (FY) 2017, the Government Accountability Office (GAO) said in a March 27 report. GAO recommended that CMS assess and strengthen documentation requirements and medical reviews to more effectively prevent improper payments.

Insufficient documentation made up 64% the estimated improper payments to Medicare in FY 2017, according to the report. In addition, providers often ignore multiple requests to provide additional documentation. CMS’ contractors allow providers up to 75 days to submit documentation and will allow providers to submit late documentation up to the program’s cut-off date for claims. In FY 2017, Medicare contractors requested additional documentation for 22,815 claims out of a sample of 50,000. In 56% of those instances, the provider did not submit additional documentation to sufficiently support the claims.

The GAO recommends that CMS:

  • Institute a process to routinely assess and take necessary steps to ensure that Medicare and Medicaid documentation requirements are necessary and effective
  • Ensure that Medicaid medical reviews provide robust information about and result in corrective actions that effectively address the underlying causes of improper payments
  • Minimize the potential for Payment Error Rate Measurement (PERM) medical reviews to compromise fraud investigations
  • Address disincentives for state Medicaid agencies to notify PERM contractors of providers under fraud investigation

HHS concurred with all but the second recommendation.