MACs process and pay claims, conduct prepayment and postpayment claim reviews, and provide Medicare fee-for-service billing education to providers in their jurisdictions. For each type of Medicare claim, the number of jurisdictions and the number of MACs that handle that type of claim vary. For Medicare Part A and B claims—handled by A/B MACs— there are 12 jurisdictions in which 8 MACs operated at the time of our review. Three of these MACs also processed home health and hospice claims in addition to Medicare A/B claims and therefore served as MACs for the four home health and hospice (HH+H) jurisdictions. For durable medical equipment (DME), including orthotics, prosthetics, and supplies— handled by DME MACs—there are four jurisdictions in which two MACs operated at the time of our review. A MAC can operate in more than one jurisdiction and handle more than one type of Medicare claim. For example, a MAC can operate as an A/B MAC in one jurisdiction and a DME MAC in another. (For maps of the 20 jurisdictions, see app. I.) The provider education department is part of a MAC’s provider customer service program, which is intended to provide timely information, education, and training to providers on Medicare fee-for-service billing, as outlined in CMS’s provider customer service program manual. The costs for MACs’ provider education departments average 2.1 to 3.3 percent of their total annual costs. MACs’ provider education department efforts are aimed at educating providers and their staff on Medicare program fundamentals, national and local policies and procedures, new Medicare initiatives, significant changes to the Medicare program, and issues identified through data analyses. Provider education departments provide education through a variety of methods, such as webinars, online tutorials available on- demand, ‘ask-the-contractor’ teleconferences, seminars at national conferences and association meetings, and website articles. These efforts are designed to educate many providers at the same time or individual providers via one-to-one education. Attendance at provider education department events is voluntary on the part of the providers. MACs are required to report their provider education department efforts monthly into the Provider Customer Service Program Contractor Information Database that CMS oversees and maintains. CMS also requires the MACs to submit a semi-annual Provider Customer Service Program Activities Report that summarizes and recounts Provider Customer Service Program activities, process improvements, and best practices during the reporting period. MACs’ medical review departments identify areas vulnerable to improper billing, review medical records to determine whether Medicare claims are medically necessary and properly documented, conduct one-to-one education as a result of claim reviews, and provide referrals to the provider education department for further education. This department frequently works with the provider education department to conduct educational efforts focusing on correcting provider billing (see fig. 1). CMS requires each MAC to identify areas vulnerable to improper billing in its jurisdiction(s) to guide MAC efforts in medical review and provider education. Areas identified by the MACs are listed in their IPRS reports. MACs’ medical review departments identify these areas by analyzing various internal and external data, such as data from CMS’s Comprehensive Error Rate Testing (CERT) program, issues identified by recovery auditors, Office of Inspector General reports, comparative billing reports, and internal MAC data. The objective of the CERT program is to estimate the payment accuracy of the Medicare fee-for-service program, which results in a Medicare fee-for-service improper payment rate. Improper payment rates are computed at multiple levels: nationally, by MAC, by service, and by provider type. According to CMS’s provider customer service program manual, MACs with improper payment rates a certain percentage above HHS’s target for determining progress toward one of its Government Performance and Results Act of 1993 (GPRA) goals may be required by CMS to submit quarterly or monthly provider education department status updates. However, CMS officials told us that they have never required any MAC to submit these quarterly or monthly status updates and they are considering removing this requirement from the manual. The probe and educate reviews are a CMS strategy to determine the extent to which providers understand recent policy changes for certain areas vulnerable to improper billing and help providers improve billing in these areas through a review of a sample of claims from every provider. Under the reviews, MAC medical review departments, with varying levels of coordination with the provider education departments, sample and review a certain number of claims from each provider to determine whether the claims were billed and documented properly. These reviews are resource intensive, because they involve manual review of associated medical records by trained medical review staff. Because of the resources involved, manual reviews are done infrequently in the Medicare program, with less than 1 percent of all Medicare claims receiving manual review. Following the first round of review, providers are informed of their results and those who billed and documented a specified percentage of claims improperly are offered voluntary one-to-one education to learn why each claim was approved or denied. Providers that billed and documented a specified percentage of claims properly are excluded from subsequent rounds of review, if any. MACs may repeat this process for subsequent rounds of review using a new sample of claims. (See fig. 2.) In addition to the areas vulnerable to improper billing identified by the MACs, CMS identified two areas vulnerable to improper billing—short- stay hospital visits and home health services—and required MACs to conduct probe and educate reviews for each of these areas. The first probe and educate review examined short-stay hospital claims to determine the extent to which certain hospitals were properly applying the “two-midnight rule” that CMS implemented effective October 1, 2013. Under the rule, hospital stays for Medicare beneficiaries spanning two or more midnights should generally be billed as inpatient hospital claims. Conversely, hospital stays not expected to span at least two midnights should generally be billed as outpatient hospital claims. From October 1, 2013, through September 30, 2015, 64,776 short-stay inpatient hospital claims were reviewed by the MACs over three rounds. Beginning on October 15, 2015, quality improvement organizations began conducting these reviews at the direction of CMS. At the direction of CMS, MACs began conducting probe and educate reviews of home health agency claims on October 1, 2015, for episodes of care that occurred on or after August 1, 2015. Round 1 was completed as of September 30, 2016, and the second round began on December 15, 2016. The purpose of these reviews is to ensure that home health agencies understand the new patient certification requirements that became effective January 1, 2015. These requirements stipulate that the referring physician, also referred to as the ordering or referring provider, must certify a patient’s eligibility for home health services as a condition of payment. As part of the certification, the referring provider must document that a face-to-face patient encounter occurred within a certain time frame. In addition, the patient’s medical record must support the certification of eligibility. MAC officials state that their provider education department efforts focus on areas vulnerable to improper billing. We found that these efforts are subject to limited oversight by CMS. Additionally, CMS does not require MACs to educate referring providers on documentation requirements for DME and home health services. MAC officials told us that their provider education departments focus education on areas vulnerable to improper billing, including those they’ve identified and listed in their annual IPRS reports. There were 278 areas listed in the IPRS reports we reviewed, and based on our analysis, some of these areas, such as skilled nursing facilities, ambulance services, and blood glucose monitors, were identified by a majority of MACs. A detailed description of the problem areas may also be identified in these IPRS reports, as illustrated by the examples below. Part A. A majority of Part A MACs reported claims from skilled nursing facilities and inpatient rehabilitation facilities as vulnerable to improper billing. Examples of reported problem areas within skilled nursing facilities included claims for individuals using an “ultrahigh” level of therapy and episodes of care greater than 90 days. Part B. A majority of Part B MACs reported claims for evaluation and management and ambulance services as areas vulnerable to improper billing. Examples of reported problem areas within the evaluation and management category included the incorrect level of coding for office visits, hospital visits, emergency room visits, and home visits for assisted living and nursing homes. DME. A majority of DME MACs reported claims for glucose monitors, urological supplies, continuous positive airway pressure (CPAP) devices, oxygen, wheelchair options and accessories, lower limb prosthetics, and immunosuppressive drugs as areas vulnerable to improper billing. An example of a reported problem area with oxygen billing was that the beneficiary medical record documentation did not provide support for symptoms that might be expected to improve with oxygen therapy. HH+H. Half of the HH+H MACs reported claims for home health therapy services and home health or hospice stays that were longer than average as areas vulnerable to improper billing. An example of a reported problem area with home health therapy services included claims from home health providers reporting a high average number of therapy visits for their patients as compared to their peers within the state and the MAC’s jurisdiction. CMS collects limited information on MACs’ provider education department efforts that focus on areas vulnerable to improper billing. CMS officials told us that they oversee the extent to which MACs’ provider education department efforts focus on areas vulnerable to improper billing by reviewing MACs’ IPRS reports. Although the IPRS reports focus mainly on how the medical review departments will address the areas identified as vulnerable to improper billing, CMS’s instructions to the MACs state that they should also include information on related provider education department activities or provider education department referrals. However, the IPRS reports we reviewed lacked specifics indicating how provider education department efforts focused on 74 percent of the 278 MAC-identified areas vulnerable to improper billing.