This department  frequently works with the provider education department to conduct  educational efforts focusing on correcting provider billing (see fig. 1). The objective of the CERT program is  to estimate the payment accuracy of the Medicare fee-for-service  program, which results in a Medicare fee-for-service improper payment  rate. Probe and Educate Reviews

The probe and educate reviews are a CMS strategy to determine the  extent to which providers understand recent policy changes for certain  areas vulnerable to improper billing and help providers improve billing in  these areas through a review of a sample of claims from every provider. 2.) MAC Officials State Their Provider Education Efforts Focus on Areas Vulnerable to Improper Billing; CMS Oversight and Requirements for These Efforts Are Limited

MAC officials state that their provider education department efforts focus  on areas vulnerable to improper billing. 3). According to CMS officials, they do not require IPRS reports to have a  certain level of specificity regarding how provider education department  efforts focus on areas vulnerable to improper billing because they do not  want to be overly prescriptive regarding MACs’ provider education  department efforts. CMS’s collection of limited information is inconsistent with federal  internal control standards related to information and communications,  which state that management should use quality information to achieve  the entity’s objectives—CMS’s objective in this instance being the  education of providers about proper billing. Unless CMS requires  sufficient MAC provider education department reporting, it cannot ensure  that MACs’ provider education department efforts are focused on areas  vulnerable to improper billing. CMS Does Not Require MACs to Educate Referring Providers for Durable Medical Equipment and Home Health Services

CMS does not require A/B MACs to educate referring providers on  documentation requirements for ordering DME and home health services  because referring providers do not bill for any DME or home health  services on these orders. The  absence of a requirement for MACs to educate referring providers about  proper documentation for DME and home health claims is inconsistent  with federal internal control standards, which state that in order to achieve  an entity’s objectives, management should assign responsibility, and  delegate authority. Without explicitly requiring that MACs educate  referring providers, the billing errors that result from referring providers’  insufficient documentation may persist. CMS Officials Consider Hospital Probe and Educate Reviews a Success, but Did Not Measure Effectiveness

Although CMS officials consider the MACs’ short-stay hospital probe and  educate reviews to be a success, they did not measure the effectiveness  of this new strategy in reducing improper billing. We found that the effectiveness of the MACs’ short-stay hospital probe  and educate reviews cannot be confirmed because CMS did not establish  performance metrics to determine whether the probe and educate  reviews were effective in reducing improper billing. Additionally, the percentage of claims denied in each round also remained high throughout the three rounds (see table  1). Therefore, without performance metrics,  CMS cannot determine whether future probe and educate reviews would  be effective in reducing improper billing. In order to reduce the high improper payment rates for home health and  DME, education on proper documentation for providers who refer their  patients for DME and home health services is necessary; however, MACs  are not required to provide this education to the referring providers. Recommendations for Executive Action

To ensure MACs’ provider education efforts are focused on areas  vulnerable to improper billing and to strengthen CMS’s oversight of those  efforts, we recommend that CMS take the following three actions:  1. CMS should require sufficient detail in MAC reporting to allow CMS to  determine the extent to which MACs’ provider education department  efforts focus on areas identified as vulnerable to improper billing. 2. For any future probe and educate reviews, CMS should establish  performance metrics that will help the agency determine the reviews’  effectiveness in reducing improper billing. At that time, we will send copies to the Secretary of Health  and Human Services, the Administrator of the Centers for Medicare &  Medicaid Services, and other interested parties.
Why GAO Did This Study

For fiscal year 2016, HHS reported an estimated 11 percent improper payment rate and $41.1 billion in improper payments in the Medicare fee-for-service program. To help ensure payments are made properly, CMS contracts with MACs to conduct provider education efforts. CMS cites the MACs’ provider education department efforts as an important way to reduce improper payments.
GAO was asked to examine MACs’ provider education department efforts and the results of MACs’ probe and educate reviews. This report examines (1) the focus of MACs’ provider education department efforts to help reduce improper billing and CMS oversight of these efforts and (2) the extent to which CMS measured the effectiveness of the MAC probe and educate reviews. GAO reviewed and analyzed CMS and MAC documents and MAC probe and educate review data for 2013-2016; interviewed CMS and MAC officials; and assessed CMS’s oversight activities against federal internal control standards

What GAO Found

Medicare administrative contractors (MAC) process Medicare claims, identify areas vulnerable to improper billing, and develop general education efforts focused on these areas. MAC officials state that their provider education departments focus their educational efforts on areas vulnerable to improper billing; however, the Centers for Medicare & Medicaid Services' (CMS)--the agency within the Department of Health and Human Services (HHS) that administers Medicare--oversight and requirements for these efforts are limited.
CMS collects limited information about how these efforts focus on the areas MACs identify as vulnerable to improper billing. According to CMS officials, the agency has not required the MACs to provide specifics on their provider education department efforts in these reports because it does not want to be overly prescriptive regarding MAC provider education department efforts. Federal internal control standards state that management should use quality reporting information to achieve the entity's objectives. Unless CMS requires sufficient MAC provider education department reporting, it cannot ensure that the departments' efforts are focused on areas vulnerable to improper billing.
CMS does not require MACs to educate providers who refer patients for durable medical equipment (DME), including prosthetics, orthotics, and supplies, and home health services on proper billing documentation, nor does it explicitly require MACs to work together to provide this education. HHS has reported that a large portion of the high improper payment rates in these services is related to insufficient documentation. The absence of a requirement for MACs to educate referring providers about proper documentation for DME and home health claims is inconsistent with federal internal control standards, which state that in order to achieve an entity's objectives, management should assign responsibility and delegate authority. Without an explicit requirement from CMS to educate these referring providers, billing errors due to insufficient documentation may persist.
Short-stay hospital and home health claims have been the focus of the MACs' probe and educate reviews--a CMS strategy to help providers improve billing in certain areas vulnerable to improper billing. Under the probe and educate reviews, MACs review a sample of claims from every provider and then offer individualized education to reduce billing errors. CMS officials consider the completed short-stay hospital reviews to be a success based on anecdotal feedback from providers. However, the effectiveness of these reviews cannot be confirmed because CMS did not establish performance metrics to determine whether the reviews were effective in reducing improper billing. Furthermore, GAO found the percentage of claims remained high throughout the three rounds of the review process, despite the offer of education after each round. Federal internal control standards state that management should define objectives in specific and measurable terms and evaluate results against those objectives. Without performance metrics, CMS cannot determine whether future probe and educate reviews would be effective in reducing improper billing.

What GAO Recommends

GAO recommends that CMS should (1) require sufficient detail in MAC reporting to determine the extent to which MACs' provider education department efforts focus on vulnerable areas, (2) explicitly require MACs to work together to educate referring providers on proper documentation for DME and home health services, and (3) establish performance metrics for future probe and educate reviews. HHS concurred with GAO's recommendations.