The Government Accountability Office has identified five key areas for preventing Medicare fraud, waste and abuse.
In a June 15 report, the GAO said its recommendations would also help the Centers for Medicare & Medicaid Services reduce improper payments.
"CMS has made progress in some of these areas, and recent legislation may provide the agency with enhanced authority," the report states. "However, CMS faces continuing challenges."
The GAO has designated Medicare as a high-risk program since 1990, in part because the program's size and complexity make it vulnerable to fraud, waste and abuse.
"Fraud, waste and abuse all can lead to improper payments, overpayments and underpayments that should not have been made or that were made in an incorrect amount," the GAO noted.
In 2009 the CMS estimated billions of dollars in improper payments in the Medicare program.
The five GAO recommendations are:
- Strengthening provider enrollment process and standards. Checking the backgrounds of applicants to become Medicare providers is a crucial step in reducing the risk of enrolling those intent on defrauding or abusing the program. In particular, the GAO has recommended stricter scrutiny of providers identified as particularly vulnerable to improper payments to ensure they are legitimate businesses.
- Improving pre-payment review of claims. Pre-payment reviews of claims are essential to helping ensure that Medicare pays correctly the first time. The GAO has recommended that CMS further enhance its ability to identify improper claims through additional automated pre-payment claim review before they are paid.
- Focusing post-payment claims review on most vulnerable areas. Post-payment reviews are critical to identifying payment errors and recouping overpayments. The GAO has recommended that CMS better target claims for post-payment review in the most vulnerable areas.
- Improving oversight of contractors. Because Medicare is administered by contractors, overseeing their activities to address fraud, waste and abuse is critical. The GAO found that CMS' oversight of prescription drug plan sponsors' compliance programs has been limited. However, partly in response to the GAO's recommendation, CMS oversight of these programs is expanding.
- Developing a robust process for addressing identified vulnerabilities. Having mechanisms in place to resolve vulnerabilities that lead to improper payments is vital to program management, but CMS has not developed a robust process to specifically address these. The GAO has recommended that CMS establish an adequate process to ensure prompt resolution of identified improper payment vulnerabilities.