The CMS Inadequate Process

At the end of last month, the US Government Accountability Office (GAO) released a 52 page report detailing what it sees as a failure by the CMS to establish an adequate process to:

address RAC-identified vulnerabilities that led to improper payments, such as paying duplicate claims for the same service.

Additionally the:

CMS has not yet implemented corrective actions for 60 percent of the most significant RAC-identified vulnerabilities that led to improper payments…

Finally:

CMS did not address significant vulnerabilities representing $231 million in overpayments identified by the RACs during the demonstration project. For the RAC national program, CMS developed a process to compile identified vulnerabilities and recommend actions to prevent improper payments. However, this corrective action process lacks certain essential procedures and staff with the authority to ensure that these vulnerabilities are resolved promptly and adequately to prevent further improper payments.

What does this mean to you?

Certainly, it appears the CMS plans to operate “business as usual”.

No fixes to the broken system, only the heavy hand of the RACs to swoop in, make the physicians life miserable by creating more overhead in processes and the ever-constant fear of a RAC knocking on the door and wanting money.

As none of this will get fixed in the foreseeable future, you need to cover back-side by ensuring your staff is properly trained in all aspects of medical coding.

GAO Says CMS Must Do Better

“Weakness Remains”

The Government Accounting Office (GAO) released a report on March 31, 2010, which discussed the Centers for Medicare & Medicaid Services’ (CMS) RAC process.

The report mentions the RAC pilot program and the RAC process in general and essentially says this program is working.

The report then goes on to say, there shouldn’t be a need for the RAC program:

CMS did not establish an adequate process in the 3-year demonstration project or in planning for the national program to address RAC-identified vulnerabilities that led to improper payments, such as paying duplicate claims for the same service.  CMS stated that one purpose of the demonstration project was to obtain information to help prevent improper payments. However, CMS has not yet implemented corrective actions for 60 percent of the most significant RAC-identified vulnerabilities that led to improper payments, a situation that left 35 of 58 unaddressed.

The GAO findings go on and can really make on ill as you get a view inside the incompetence of government programs.

Basically what this report is saying is, the RAC program is working, but we shouldn’t need the RAC program, the CMS should have it’s act together so it doesn’t screw up this bad.

The GAO then goes on to recommend action to fix the CMS shortfalls.  Unfortunately the actions are bland governmental reactions: “the Administrator of CMS should develop and implement a process that includes policies and procedures…” and “The Administrator of CMS should designate key personnel with appropriate authority to be responsible….”

Unfortunately typical government mumbo-jumbo.

Let’s face it, the CMS isn’t going to change how it works, and the RAC process is the “easy” way to attack this problem.

Quite frankly, we at RACGuru don’t see things changing…aside from the RAC’s coming after more and more physicians.