Medicare Administrative Contractors (“MACs”) failed to meet 26 percent of quality-assurance standards reviewed by the Department of Health and Human Services Office of Inspector General (“OIG”), according to a new report.  The OIG report found that MACs fell short on 310 of 1,201 quality-assurance standards (26 percent) that were part of the Centers for Medicare & Medicaid Services (“CMS”) reviews of MAC Quality Assurance Surveillance Plans between September 2008 and August 2011.  These reviews aim to ensure MACs have quality-control plans in place to fulfill contractual requirements.  According to the report, MACs had not resolved issues with 83 of the unmet standards.

The OIG report found that MACs had significant problems meeting quality-assurance standards for (1) provider enrollment, (2) Medicare secondary payer, and (3) appeals.  In each of these areas, MACs fell short of 40 percent or more of the standards.  For appeals, the OIG found that MACs failed to meet 43 percent of the applicable standards, which are focused on the accuracy and speed with which a MAC handles an appeal.

The OIG also found that CMS oversight of MAC quality assurance was not always timely. Further, while CMS can require MACs to submit action plans to promote future adherence, CMS did not require action plans for 37 of the standards that the MACs did not meet.  Among other recommendations, OIG asked that CMS:

  • require MACs to draft action plans for all unmet quality-assurance standards;
  • use metrics from these reviews in the MAC award fee program; and
  • comply with applicable time limits related to reviewing the MACs.

CMS agreed with the OIG’s recommendations, and as of June 19, 2013, has required MACs to submit action plans for all unmet standards.  Read the OIG’s report “Medicare Administrative Contractors’ Performance” (OEI-03-11-00740) (released Jan. 9, 2014).

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