Last week, CMS published in their blog that the 2018 Medicare Fee-For-Service improper payment rate is the lowest since 2010. Even more significant for CMS, is that for the first time in improper payment reporting history, improper payment rate reductions occurred across the board in Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP).
Improper payments are not necessarily measures of fraud, but instead are payments that did not meet statutory, regulatory, administrative, or other legally applicable requirements. These improper payments may be overpayments or underpayments and do not necessarily represent expenses that should not have occurred.
The post touts muliple preventive efforts by CMS to achieve this goal, including simplifying and clarifying policies as well as developing and implementing initiatives that ensure applicable coverage, payment and coding rules are met on the front end before services are rendered. The post also calls out the recently implemented targeted review strategy that focuses on provider education, assistance and burden reduction, more commonly known as TPE (Targeted Probe and Educate).
In fact, CMS announced that they will continue to phase in a Targeted Probe and Educate initiative to reach individual providers with educational interventions and enhance these efforts to allow for flexible and consistent user training. The goal of this outreach is to reduce provider burden, improper payments, and claim denials and appeals, while improving beneficiary quality of care and the consumer experience.
Other areas focused on reducing improper payment rates include provider enrollment and screening standards, enforcement authorities, and advanced data analytics such as predictive modeling. In other words, expect a tighter running ship at the National Supplier Clearinghouse (NSC) and even more UPIC audits across all product categories...and more audits from these contractors.
The Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) improper payments decreased an estimated $1.14 billion from 2016 to 2018. This represents a decrease in improper payment rates from 46.26 percent in 2016 to 35.54 percent in 2018. With such a significant reduction, we can expect the CMS program integrity unit to want even better results for 2019.
Ultimately, a lower improper payment rate is good news for the DMEPOS industry. Consider it a better score on our industry "report card". It shows that we are doing the right thing and are committed partners in protecting the Medicare Trust Fund.
That score, however, was achieved through successful audit programs (TPE and UPIC) and a more stringent supplier enrollment program. How prepared is your organization if faced with an audit?
The van Halem Group has a team of experts available to assist you. We offer proactive and reactive services, designed to ensure you are in compliance with payor guidelines. Whether you need to be "audit ready" or have received an audit notification and need guidance throughout the process, we are here to help.
Our audit experts can conduct proactive claim audits and provide education to your staff, affording your organization the potential to identify risk areas before the auditors do. From a reactive perspective, we can review claims selected for audit, identify potential issues and develop a corrective action plan to present to the audit contractor. We will work hard to improve your processes and get you off the audit radar. For more information, contact us today!
To view CMS's fact sheet with more information about Improper Payment Reductions, please visit the CMS Newsroom.