Medicare:

Initial Results of Revised Process to Screen Providers and Suppliers, and Need for Objectives and Performance Measures

GAO-17-42: Published: Nov 15, 2016. Publicly Released: Dec 15, 2016.

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Kathleen M. King
(202) 512-7114
kingk@gao.gov

 

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Can bad guys be kept from billing Medicare?

Screening doctors and other providers to make sure they are legitimate helps. In 2011 Medicare strengthened its screening process—for example, by visiting more doctors' offices to verify information and conducting more background checks. As a result, over 700,000 medical providers lost their Medicare billing privileges, saving an estimated $2.4 billion.

But the screening process could work even better if Medicare had ways to measure progress toward its screening goals, such as reducing payment errors. We recommend Medicare create such measures.

Medicare Enrollment Process

3 steps to become eligible to bill Medicare: application, review, decision.

3 steps to become eligible to bill Medicare: application, review, decision.

Additional Materials:

Contact:

Kathleen M. King
(202) 512-7114
kingk@gao.gov

 

Office of Public Affairs
(202) 512-4800
youngc1@gao.gov

What GAO Found

GAO's analysis of the Centers for Medicare & Medicaid Services' (CMS) Medicare enrollment data found that CMS used its revised enrollment screening process to screen and revalidate over 2.4 million unique new applications and existing enrollment records. GAO's analysis showed that the screening resulted in over 23,000 new applications being denied or rejected and over 703,000 existing enrollment records being deactivated or revoked. CMS estimates the revised process avoided $2.4 billion in Medicare payments to ineligible providers and suppliers from March 2011 to May 2015 and resulted in other benefits, such as more accurate provider and supplier enrollment data. In June 2015, GAO reported some inaccuracies in the enrollment data after the revised process took effect, such as potentially ineligible practice location addresses, which CMS has taken action to address.

Since 2011, CMS has implemented some modifications to the revised screening process and made operational modifications to its revalidation efforts. For example, CMS eliminated automatic approvals of provider and supplier requests to extend the deadline for submitting enrollment information for revalidation. CMS officials stated that they plan to implement further modifications, but have not yet identified these future modifications. CMS officials said that they are waiting to see the results of the previous modifications before modifying the enrollment process further.

CMS has set goals and conducted monitoring of the enrollment screening process, but those monitoring activities lack objectives and performance measures for assessing progress toward those goals. CMS officials said they want to assess the screening process but they are uncertain of what objectives and performance measures to establish, in part because they are concerned that some measures would be inappropriate. While there may be challenges in developing objectives and performance measures, there are opportunities to do so that would allow CMS to better monitor the enrollment screening process without setting specific targets that could create inappropriate incentives for contractors. For example, CMS could focus on developing objectives and performance measures related to its goals for enrollment screening, such as keeping enrollment information up to date. Federal internal control standards and leading practices specify defining objectives and establishing performance measures so that an agency can monitor progress toward achieving desired goals. Without objectives and performance measures to use in ongoing monitoring, CMS will be unable to measure the progress it has made toward achieving its goals.

In commenting on this report, the Department of Health and Human Services agreed with GAO's recommendation.

An effective provider and supplier enrollment process is a cornerstone of ensuring Medicare program integrity and limiting improper payments. The Patient Protection and Affordable Care Act contained provisions designed to strengthen CMS's enrollment screening process. In response, CMS implemented a revised screening process on March 25, 2011, that assigned all providers and suppliers to one of three risk categories—limited, moderate, or high—and based screening on the level of potential risk of fraud, waste, and abuse they present. The process is used to screen prospective, and revalidate enrolled, providers and suppliers. In September 2011, CMS began its first large scale revalidation effort to verify all enrolled providers' and suppliers' information and determine whether they remain eligible to bill Medicare. As of March 2016, it had begun its second large scale revalidation effort.

GAO was asked to examine the revised enrollment screening process. GAO examined 1) the results of the 2011 revised screening process, 2) CMS's implemented or planned modifications to the process, and 3) CMS's monitoring of the revised process. GAO examined enrollment data from March 25, 2011, through December 31, 2015, reviewed CMS policies and procedures, and interviewed CMS and Medicare contractor officials.

What GAO Recommends

To improve the revised screening process, CMS should establish objectives and performance measures for assessing progress toward achieving its goals.

For more information, contact Kathleen M. King at (202) 512-7114 or kingk@gao.gov.

Recommendation for Executive Action

  1. Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    Recommendation: To improve the efficiency and effectiveness of the agency's enrollment screening process, the Administrator of CMS should establish objectives and performance measures for assessing progress toward achieving its goals.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

 

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