OIG Uncovers Flaws in CMS Processes, Programs

In addition to showing the ineffectiveness of the Audit MICs, this report also may provide an early look at what to expect with Medicaid RACs. William Malm, ND, RN, CMAS, senior data projects manager at Craneware, Inc., based in Edinburgh, Scotland with a US office in Atlanta, suggests that the report essentially verifies CMS concerns about the Medicaid RAC proposed and final rules.

"States are having difficulty auditing on the Medicaid side due to the diversity and complexity of the regulations, and the lack of billing specifics in the individual state guidelines," Malm says. "These business practices have not been well documented and there is no defensible source authority to proclaim that something is an overpayment or an underpayment."

Report on CERT errors overturned through appeals
On March 9, the OIG published a review of the comprehensive error rate testing errors overturned through the appeals process for fiscal years 2009 and 2010. The report details the OIG’s review of the Medicare fee-for-service error rate, which is calculated by CMS and used in the estimate of improper payments that CMS submits to Congress each year.

CERT claim payment denials overturned after the cutoff date for determining the error rate for each fiscal year would have reduced the reported error rates from 7.8% to 7.2% for FY 2009 and from 10.5% to 9.9% for FY 2010, according to the report.