Survey of Controls Used by Medicare Carriers To Prevent Duplicate Payments

A survey was conducted of Medicare carriers' use of prepayment computer edits to prevent duplicate payments. Bureau instructions specify editing criteria to be used by carriers in screening claims to identify duplicate claims to be disallowed without clerical intervention and potential duplicate claims to be subjected to manual review. Although use of these criteria is mandatory, most of the carriers surveyed used editing criteria that varied from Bureau criteria. Regional offices are responsible for assuring that carriers use editing criteria required by the Bureau, but most regional personnel did not know what editing criteria were being used. Use of editing criteria which are too narrow results in duplicate claims not being detected, and use of criteria which are too broad can result in unnecessary manual examinations of line items. Criteria for the edit used to deny exact duplicates automatically should be changed to include comparisons with other claims still in progress. The Medicare Bureau should direct regional offices to ensure that all carriers comply with duplicate detection criteria and to show specifically the carriers' criteria in the annual contractor evaluation reports.