Health Business Blog » Since When Is a Co-pay The Cure For Fraud?

by David E. Williams

Medicare coverage for home care visits has a checkered history. The original rationale for including home care in Medicare was straightforward and compelling: it’s much cheaper, healthier and pleasant for a patient to be at home receiving skilled care than to stay in a hospital for lack of enough support in the home environment. That logic remains solid. Unfortunately it doesn’t mean Medicare spending has dropped with home care coverage in place. That’s because operators of home care agencies don’t see it as their job to reduce Medicare spending and neither do hospitals. Both want to make as much money as possible under the fee-for-service system. Home care ended up being an additional cost to the system, not a cheaper substitute for the hospital.

There have been various attempts to control home care spending. The latest is a 13-1 recommendation by the Medicare Payment Advisory Commission to impose co-payments to discourage unneeded use of home care services.
Full Article

H.R. 173: To amend titles XI and XVIII of the Social Security Act to provide increased civil and criminal... (GovTrack.us)

To amend titles XI and XVIII of the Social Security Act to provide increased civil and criminal penalties for acts involving fraud and abuse under the Medicare Program and to increase the amount of the surety bond required for suppliers of durable medical equipment.

Sponsor:	Rep. Clifford Stearns [R-FL6](no cosponsors) Cosponsors:
Text:	The text of this legislation is not yet available on GovTrack. It may not have been made available by the Government Printing Office yet.
Status:	Introduced Jan 5, 2011 Referred to Committee View Committee Assignments Reported by Committee ... House Vote ... Senate Vote ... Signed by President ... This bill is in the first step in the legislative process. Introduced bills and resolutions first go to committees that deliberate, investigate, and revise them before they go to general debate. The majority of bills and resolutions never make it out of committee. [Last Updated: Jan 6, 2011 11:33AM]
Last Action:	Jan 5, 2011: Referred to House Energy and Commerce

Current Status

Confidentiality Cloaks Medicare Abuse - WSJ.com

By MARK SCHOOFS And MAURICE TAMMAN


Physical therapy, which cost Medicare almost $3.5 billion in 2008, offers a case study in how Medicare polices its payments. Even when Medicare identified providers whose physical-therapy billing raised red flags, it kept paying thousands or even millions of dollars, sometimes for years, The Wall Street Journal found. Among the cases:

•A physical therapist in Brooklyn who billed for so much therapy—more than $2.5 million in 2008 alone—that it would have been virtually impossible for him to have performed it all within state and Medicare guidelines, fraud experts say. Medicare has continued to pay him, shelling out nearly a million dollars through July of this year.

•A second doctor in Florida who pocketed more than $1.8 million from Medicare in 2007, much of it from physical therapy on patients with an extremely rare condition. Even after a Medicare antifraud contractor flagged this doctor, the agency paid him at least $6.7 million over more than two years.

•A Houston doctor whose Medicare billing under her provider number spiked from zero to more than $11.6 million in less than a year. At the time, this doctor was being investigated for misconduct in a company owned by a Nigerian with an alleged history of fraud.

There are plenty of reasons why Medicare often fails to stop questionable payments up front. To protect law-abiding doctors and hospitals—the vast majority—Medicare is required to pay nearly everybody within 30 days. Medicare says it is reluctant to suspend payments to providers who may have made honest mistakes, out of concern that beneficiaries might go without needed treatment. Law-enforcement agencies and Medicare contractors, overwhelmed by the sheer volume of Medicare fraud cases, can't investigate and prosecute them all. Sometimes, prosecutors and investigators ask Medicare to keep paying so as not to tip off targets of an investigation.

But a central problem is that Medicare hasn't fully exploited its most valuable resource: its claims database.
Full Article

The ACA’s New Weapons against Health Care Fraud | Health Care Reform Center

by John K. Iglehart in the New England Journal of Medicine

Marshaling expanded financial resources, aggressive new legal authority, and rare bipartisan solidarity, the Obama administration is accelerating federal efforts to fight health care fraud, waste, and abuse that cost taxpayers and private insurers billions of dollars every year. Although the new forms of authority are granted by the Affordable Care Act (ACA), which Republicans unanimously opposed, most GOP legislators strongly support — and some even sponsored measures to enable¹ — the more rigorous crackdown on illegal activities that plague Medicare, Medicaid, and private insurers. Under past policies, Congress and the executive branch “way, way, way” underspent on fighting health care fraud, according to Kerry Weems, who was acting administrator of the Centers for Medicare and Medicaid Services (CMS) from 2007 to 2009.²
 
Since 1990, the Government Accountability Office (GAO) has designated Medicare as a high-risk federal program because its vast size and complexity make it vulnerable to fraud, waste, and abuse. In 2009, government-wide “improper payments” totaled $98 billion — more than half of it paid by Medicare and Medicaid. It is uncertain how much of the activity that resulted in these payments was actual fraud, but Lewis Morris, chief counsel of the Office of Inspector General (OIG), Department of Health and Human Services (DHHS), told the Senate Finance Committee last year, “Although we cannot measure the full extent of health care fraud in Medicare and Medicaid, everywhere we look we continue to find fraud in these programs.” The National Health Care Antifraud Association, an organization of some 100 private insurers and public agencies, estimates conservatively that $60 billion of total national health care spending each year is accounted for by fraud.

Continue Reading

Related articles by Zemanta

• Federal Agencies Will Establish A 'Do Not Pay List' To Prevent Fraud (medicalnewstoday.com)
• Medicare Fraud Enforcement Efforts Recovered $2.5 Billion In 2009 (huffingtonpost.com)
• New Tools Help Fight Health Care Fraud (huffingtonpost.com)
• REP. DARRELL ISSA: The Lackluster Record of Government Health Care: Already Medicare, which acc... (pajamasmedia.com)

BENEFICIARIES REMAIN VULNERABLE TO SALES AGENTS’ MARKETING OF MEDICARE ADVANTAGE PLANS

Image via Wikipedia

The Centers for Medicare & Medicaid Services (CMS) contracts with private companies, known as plan sponsors, to provide health insurance plans under MA. Plan sponsors may market their MA plans through independent sales agents, who may market on their own or through a field marketing organization (FMO), or by employing their own sales agents.

Between June 2007 and June 2008, Congress held three hearings examining sales agents’ marketing of MA plans. During these hearings, witnesses testified that sales agents had marketed without licenses, portrayed themselves as Medicare employees, and misled Medicare beneficiaries about plan benefits. These types of aggressive, deceptive, and fraudulent marketing practices could result in Medicare beneficiaries enrolling in plans that do not meet their health care needs. Several members of Congress raised concerns about sales agents’ marketing to Medicare beneficiaries to the Office of Inspector General (OIG); one specifically requested that OIG examine the marketing practices of MA plans.

In July 2008, Congress enacted the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), which prohibited or limited certain marketing activities by sales agents and plan sponsors. In September 2008, CMS published regulations implementing the MIPPA’s marketing provisions, including limiting sales agent compensation to independent sales agents. In addition, CMS regulations required that all sales agents be trained and tested annually and be State licensed. To examine selected MA plan sponsors’ compensation of sales agents and determine whether the selected plan sponsors ensured that their sales agents were qualified, we reviewed compensation, testing, and licensure data for a random sample of sales agents. We purposively selected the plan sponsors based on their size and the rate of marketing complaints they received. We also compared complaints regarding sales agent marketing reported to CMS from 2008 and 2009 to determine whether the number and topics of Medicare beneficiaries’ complaints changed after implementation of the sales agent marketing regulations.

FINDINGS
*All five plan sponsors using independent sales agents had compensation practices that resulted in inappropriate financial incentives.
*Five of the six selected plan sponsors did not ensure that all sales agents were qualified under CMS’s regulations.
*The number and topics of sales agent marketing complaints remained unchanged after implementation of sales agent marketing regulations. Read More/Download Report

Sebelius, West Highlight New Tips to Prevent Medical Identity Theft and Medicare Fraud

Image via Wikipedia

New Information Available at www.StopMedicareFraud.gov

Secretary of Health and Human Services Kathleen Sebelius and Assistant Attorney General Tony West today highlighted the Obama Administration’s work to fight Medicare Fraud and released new tips and information to help seniors and Medicare beneficiaries deter, detect and defend against Medical identity theft. Medical identity theft occurs when someone steals a patient’s personal information, such as his or her name and Medicare number, and uses the information to obtain medical care, to buy drugs or supplies, or to fraudulently bill Medicare using that patient’s stolen identity. The new tips and a printable brochure were produced by the HHS Office of the Inspector General (OIG) and are available now at www.StopMedicareFraud.gov and www.oig.hhs.gov/fraud/idtheft.

“When criminals steal from Medicare, they are stealing from all of us. That’s why fighting Medicare fraud is one of the Obama Administration’s top priorities,” said Secretary Sebelius. “Preventing medical identify theft is an important part of our work to stop Medicare fraud, and these tools will give seniors important information about how to deter, detect and defend against ID theft and fraud.”

“This Administration is committed to guarding Medicare against fraud and abuse,” noted Assistant Attorney General West. “The Department of Justice (DOJ), in collaboration with our partners at the Department of Health and Human Services (HHS), will continue to protect the integrity of the nation’s public health programs and vigorously pursue those who seek to take advantage of our most vulnerable citizens.”

“Medical identity theft can disrupt your life, damage your credit rating, and threaten your health if inaccurate information ends up in your medical records,” added HHS Inspector General Daniel R. Levinson. “OIG’s special agents frequently uncover fraud schemes that involve the sale and use of stolen Medicare identification numbers. We’re cracking down on these schemes and working to help stop medical identity theft before it happens.”

The materials released today include practical steps to help “deter, detect, and defend” against medical identity theft. Beneficiaries are reminded to beware of offers of free medical equipment, services, or goods in exchange for their Medicare numbers. Beneficiaries are also encouraged to regularly review their Medicare Summary Notices, Explanations of Benefits statements, and medical bills for suspicious charges and to report suspected problems.

The effort to help prevent medical identity theft is one part of the Obama Administration’s work to crack down on Medicare fraud. In May, Attorney General Eric Holder and Secretary Sebelius announced the creation of a new interagency effort, the Health Care Fraud Prevention and Enforcement Action Team (HEAT), to combat Medicare fraud. The HEAT team includes senior officials from DOJ and HHS. HEAT team efforts include the expansion of joint DOJ-HHS Medicare Fraud Strike Force teams that have been successfully fighting fraud in South Florida and Los Angeles to additional cities including Detroit and Houston. Established in 2007, these teams have a proven record of success using data analysis techniques and community policing to identify, investigate and prosecute on-going fraud.

The Centers for Medicare & Medicaid Services (CMS) has undertaken other steps to fight fraud and protect beneficiaries who buy durable medical equipment or rely on home health services. On October 1, all durable medical equipment suppliers across the nation, except for pharmacies, must be certified by Medicare, a requirement that assures beneficiaries that their suppliers are valid businesses and meet Medicare’s financial and quality standards.

At today’s event, Sebelius also highlighted the SMP programs and was joined by SMP volunteer Joanna T. Gibson of Felton, Del. Formerly known as Senior Medicare Patrol programs, the SMP programs are funded by HHS’ Administration on Aging and help Medicare and Medicaid beneficiaries prevent, detect, and report health care fraud. Because this work often requires face-to-face contact to be most effective, SMPs nationwide recruit and train nearly 5,000 volunteers every year to help in this effort. Most SMP volunteers are both retired and Medicare beneficiaries and thus well-positioned to assist their peers.

“We all have to pitch in and do what we can to prevent our Medicare dollars from being wasted on fraud,” said Gibson. “And we can start by learning more about what Medicare covers, reading our Medicare statements, and reporting provider charges that just don’t seem right.”

To learn more about stopping Medicare fraud, visit www.StopMedicareFraud.gov. To report suspected Medicare fraud call the Inspector General’s toll-free Hotline at 800-447-8477 (800-HHS-TIPS). The toll-free TTY number is 800-377-4950.

Sebelius, West Highlight New Tips to Prevent Medical Identity Theft and Medicare Fraud