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ENHANCE PROGRAM INTEGRITY
TO SAFEGUARD MEDICARE FROM LOSS
Evidence:
United States. Government Accountability Office. "Medicare: High Risk Issue." 30 Nov 2018
CMS needs to continue to take action to reduce its payment error rates of $51.9 billion in fiscal year 2017 to better ensure the integrity of the Medicare program.
CMS needs to improve its processes for selecting MA contracts to include in its risk adjustment data validation audits. These audits determine whether beneficiary health status information that MA organizations used to assess risk was supported by medical records, facilitating the recovery of improper payments. CMS estimated that it improperly paid $14.1 billion in 2013 to MA organizations. Additionally, CMS should enhance the timeliness of these audits.
CMS has tested and, in some cases, implemented prior authorization – requiring certain providers and suppliers to obtain Medicare approval before beneficiaries can receive certain services or items like powered wheelchairs – in an effort to reduce improper payments. Prior authorization, which started in 7 states in 2012, reduced spending on these items and services by as much as $1.9 billion. Since most prior authorization programs are scheduled to end in 2018, CMS should take steps to continue prior authorization.
The Patient Protection and Affordable Care Act (PPACA) provided CMS with certain authorities to combat fraud, waste, and abuse in Medicare. CMS should fully exercise these authorities, including the authority to require a surety bond for certain at-risk providers, which would guarantee that CMS can recover losses from a provider or supplier that does not fulfill its obligation to Medicare.