Medicare paid providers for medical services that were authorized and also covered by the Veterans Affairs’ community care programs between January 2017 and December 2021. This led to duplicate payments of up to $128 million, an audit by the Office of Inspector General (OIG) found.
The audit, published Monday, examined $19.2 billion in Medicare Parts A and B payments for 36.2 million claims of people eligible for both Medicare and Veterans Health Administration (VHA) benefits.
“VHA is solely responsible for paying for the community care services it authorized. Medicare payment for other services not authorized by VA may be made in accordance with Medicare requirements,” the OIG stated. “Duplicate claims occur when a provider submits claims for the same services to both Medicare and VHA, and duplicate payments occur when both programs pay the claims.”
These duplicate payments might not have occurred had the Centers for Medicare and Medicaid Services (CMS) implemented the right controls, such as having a data-sharing agreement with the VHA and including VHA enrollment, claims and payment data in CMS’ data repository.
“Inclusion of these data, which is required by Federal law, would have allowed CMS to compare VHA claims data with existing Medicare claims data to identify duplicate claims paid for by both Medicare and VHA,” the audit said. “Because CMS did not develop an interagency process, CMS did not establish an internal process (such as claims processing system edits) to address duplicate payments for medical services authorized and paid for by VHA.”
In addition, CMS did not inform providers to not bill Medicare for medical services that were authorized by the VHA, the OIG said.
The OIG suggested several changes for CMS, including a data-sharing agreement with the VHA and an “interagency process” to add VHA enrollment, claims and payment data into the CMS Integrated Data Repository. It also recommended creating an internal process that would “address duplicate payments.” Lastly, the OIG said that CMS should inform providers to not bill Medicare for services authorized by the VHA.
CMS agreed with the OIG’s recommendations and said it is working to address duplicate payments, according to the audit.
“CMS previously informed us that establishing a long-term solution to address duplicate payments will take time,” the OIG said. “We acknowledge that CMS is working toward establishing a datasharing agreement for the ongoing sharing of data and is working to develop processes to address duplicate payments.”
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