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Diane Publishing Books
Medicare Program Integrity: Greater Prepayment Control Efforts Could Increase Savings and Better Ensure Proper Payment
Kathleen M. King (au)
The Centers for Medicare and Medicaid Services (CMS) reported an improper payment rate of 8.6% ($28.8 billion) in the Medicare fee-for-service program for FY 2011. To help ensure that payments are made properly, CMS uses controls called edits that are programmed into claims processing systems to compare claims data to Medicare requirements in order to approve or deny claims or flag them for further review. This report assesses the use of prepayment edits in the Medicare program and CMSäó»s oversight of Medicare administrative contractors (MACs), which process claims and implement some edits. It examines the extent to which (1) CMS and its contractors employed prepayment edits; (2) CMS has designed adequate processes to determine the need for and to implement edits based on national policies; and (3) CMS provides information, oversight, and incentives to MACs to promote use of effective edits. Tables and figure. This is a print on demand report.
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