Policing of Medicare Cuts Fraudulent Providers, Suppliers

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In the past two years, 14,663 providers and suppliers have been banned from billing Medicare in response to findings involving fraudulent activity.

The figure, according to USA Today, is about 2.5 times the number from the prior two-year period, and in some states that number reflects a quadrupling of revocations, according to Health and Human Services Statistics.

“We have always been doing some of this,” Peter Budetti, Center for Medicare Services (CMS) deputy administrator for program integrity, told USA Today. “But there has been a special focus under the Affordable Care Act,” Budetti added.

Administration officials were to announce new fraud numbers and note that they are continuing to prompt seniors for more help in fighting fraud. For example, one proposed rule would enable fraud reporters to earn up to $9.9 million in reward money under the new fraud-prevention program, according to USA Today. Previously, beneficiaries were paid up to $10,000 for tips leading to fraud money recovery.

One new element of the anti-fraud campaign, said Budetti, is a new, clearer summary statement that will enable recipients to better understand who may have used their identification numbers to bill Medicare. Budetti told USA Today that he considers this a “landmark change.”

“Our best weapon in fighting fraud is our 50 million Medicare beneficiaries,” he said. The hope is that increasing the reward incentive to a proposed $9.9 million would “attract the kind of attention” the government needs, Budetti said.

The government has recovered $14.9 billion in Medicare fraud money in the past four years, largely due to the 2010 Affordable Care Act in which the government is allowed to review data to find signs of fraud and cease payments to fraudulent providers, USA Today explained. Those providers would then have to reapply to be considered for Medicare participation. Providers unable to meet the requirement, that have incorrect addresses, or that are improperly licensed are not permitted to bill Medicare.

Meanwhile, nursing homes nationwide were previously found to be overcharging the Medicare system about $1.5 billion annually, according to a federal study. In fact, a report from the Department of Health and Human Services found that one in four bills received from nursing homes to the Medicare system contained overcharges for services that were either not performed or deemed unnecessary. Some nursing homes “upcode” the services they provide patients covered by Medicare because they’re confident they’ll receive a full reimbursement.

In many instances, the upgraded, or more intensive care, was never performed and was added to a patient’s bill when the bill was sent to the government for payment. In some cases, the care billed to Medicare for patients was deemed unnecessary and would provide no clinical benefit, according to a prior The Wall Street Journal report. In a single example highlighted by the source, a patient under hospice care had refused a specific treatment, but Medicare was billed by the nursing home anyway.

The Journal previously reported that Medicare spending may be the single largest drain on the national budget, with at least 13.5 percent of all federal spending dedicated to Medicare. Some experts interviewed by the Journal indicated that as much as 30 percent of all government spending on healthcare is wasteful, be it on unnecessary services, unperformed services, or undelivered or unnecessary pharmaceuticals.