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Healthcare seeks clearer guidance, fewer audits

By Joe Carlson
Posted: April 27, 2013 - 12:01 am ET

The healthcare industry wants clearer rules, fewer redundant audits and more focus on proactive healthcare fraud prevention.

The Senate Finance Committee was swamped with more than 150 reports totaling 2,000 pages from healthcare providers, insurers and suppliers last year after asking for suggestions on ways to prevent waste and improve fraud-fighting efforts in Medicare and Medicaid. About $65 billion was lost to improper payments from Medicare in 2011, according to one government estimate.

The request for input came as a staff member for the influential Senate committee revealed that a group of senators was interested in probing the effectiveness and efficiency of the CMS' array of independent auditing firms. After an outpouring of criticism about costly and duplicative auditing reflected in the public comments, the senators asked the Government Accountability Office to audit the auditors.

Kim Brandt, chief oversight counsel to the committee's ranking Republican, Sen. Orrin Hatch, said last week during the annual meeting of the Health Care Compliance Association in National Harbor, Md., that the GAO report will attempt to examine how the administrative burden placed on healthcare providers compares with the amount of money recovered by the audits.

“Are all these audits worth it in the long run?” Brandt asked, adding that the first of two GAO reports on the topic is slated for release in early summer. Brandt was the CMS' director of Medicare integrity from 2003 to 2010.

In total, 54 of the reports the committee received gave recommendations addressing the audit burden on healthcare providers, including numerous calls for the CMS to simplify and standardize the auditing process and provide better examples of how to document medical necessity for Medicare procedures.

Meanwhile, more than three-quarters of the comments addressed the related issue of how to reform the system for detecting improper payments.

Providers and insurers also suggested that the CMS revise the requirements for the medical-loss ratio so that payers can count fraud-prevention efforts as a medical expense rather than an administrative one.

Commenters also said the CMS could allow Medicare beneficiaries at risk of abusing or diverting addictive medications to be restricted to certain providers and have their prescriptions tracked in real time.

Jo-Ellen Abou Nader, senior director of program integrity at Express Scripts, told Modern Healthcare recently that the topic of giving contractors this ability to “lock in” high-risk prescription users has been raised several times with the CMS in the past.

Follow Joe Carlson on Twitter: @MHJCarlson

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