The Centers for Medicare and Medicaid Services has reported that initiatives to address improper payments–long a focus of GAO, OMB and Congress–are yielding results, with the rate in its fee-for-service program now 8.12 percent, the lowest since 2010 and representing a $4.6 billion decrease from 2017.
“For the first time in improper payment reporting history, we have achieved improper payment rate reductions across the board in Medicare, Medicaid, and the Children’s Health Insurance Program,” a fact sheet says. Rates decreased from 58.95 percent in 2015 to 17.61 percent in 2018 for home health care; from 9.33 to 6.55 percent in skilled nursing facility care over 2017-2018; and from 46.26 to 35.54 percent since 2016 for durable medical equipment and supplies, it said.
It attributed the reductions to steps including: “policy clarifications and simplifications; prior authorization initiatives that ensure applicable coverage, payment, and coding rules are met before services are rendered; a targeted probe and educate medical review strategy that focuses on outlier providers, limits the number of medical records requested, and puts emphasis on education and assistance in correcting claims errors; and provider education on Medicare policy.”
It said that additional initiatives under consideration include expanded requirements for prior authorization for durable medical equipment and supplies, and making documentation and prior authorization requirements more visible to clinicians through electronic health records.
By the government’s definition, improper payments do not necessarily indicate fraud or even overpayments, but also include underpayments and correct payments that are not properly documented.