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The RAConteur: Another Opinion on Government Audits

Posted by J. Paul Spencer, CPC, CPC-H in The RAConteur™

Given the increasing incompetence in our society, I feel that with each passing day there are more jobs that I myself could perform. Yet there is one exception, and that would be the job of sports referee. It takes either a special level of off-the-chart arrogance regarding your own skills or a deep-seeded self-hatred to be a referee. Every decision that a referee makes guarantees that one-half of the participants in the sporting contest will come away hating you.

In the world of government audits in the last week, we heard from one such policy referee, that being the General Accounting Office (GAO).

The GAO is officially the investigative arm of Congress. It operates as the actuarial governor on Congressional legislation, reviewing the receipt and payment of public funds to gage the financial impact of legislation. Much like a referee, the reports released by the GAO tend to briefly alienate political factions based on whether the reports fit a particular party narrative. A report released last Wednesday was no exception.

The GAO chastised the Department of Health & Human Services for not implementing past recommendations to reduce improper payments from the Medicare program. The most prominent of the GAO’s recommendations was CMS demanding automated prepayment edits of the Medicare Administrative Contractors (MACs) in order to identify improper claims. This recommendation was first brought forward in 2007 and remains an elusive goal.

In addition, the GAO wants to see payments to Medicare Advantage plans to reflect the correct health status of the beneficiary in question. Risk Adjustment Data Validation (RADV) audits have revealed that the Medicare Part C plans have been claiming more dollars than they are entitled to based on patient condition, so this GAO recommendation should gain some traction. In addition, the GAO wants to see the current Medicare Advantage Quality Bonus Payment Demonstration halted, as it claims the design of the program precludes it from yielding meaningful results.  

It is one thing for the Senate Finance Committee to request input from stakeholders on how to avoid waste, fraud and abuse in the Medicare program. It is quite another for the GAO to state that there is more that CMS could do to fight improper payments, in addition to RACs, ZPICs and predictive modeling technology, all of which have been shown to be failing in their own unique ways. The injection of the GAO as an impartial observer into the debate should be welcomed by a provider community left shell-shocked from audit activity. For this one time, everyone should rejoice in the arrival of the referee.

3 Responses to “The RAConteur: Another Opinion on Government Audits”

  1. [...] Click here to visit the original article. Tagged with: CMS • GAO • HHS • Medicare Part C • Predictive Modeling • rac • RAC / Recovery Audit Contractors • rac audit • RADV Audits • recovery audit contractor • Senate Finance Committee • The RAConteur™ • ZPIC  If you enjoyed this article, please consider sharing it! [...]

  2. [...] timing of the release of this report requires some critical thinking as well. I wrote a few weeks ago about the U. S. Senate Finance Committee requesting “white papers” from [...]

  3. [...] timing of the release of this report requires some critical thinking as well. I wrote a few weeks ago about the U. S. Senate Finance Committee requesting “white papers” from [...]

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