Fraud probe caseload getting to be a burden
April 1, 1999
Fraud probe caseload getting to be a burden
FBI investigating 2,800 cases
The Federal Bureau of Investigation is currently investigating approximately 2,800 cases of health care fraud nationwide, a top official reported recently.
Joseph Ways, chief of the FBI’s healthcare fraud unit, told the Second Annual National Congress on Health Care Compliance in Washington, DC, on Feb. 12 that 420 of the FBI’s 11,000 agents have been assigned to investigate health care fraud cases. Each of these agents is currently working an average of just under seven cases.
"That’s a pretty heavy caseload for a paper-intensive, white-collar case," Ways said. The caseload "is one of the reasons [the FBI] is very strongly pushing for joint investigations where we can bring in the other agencies and outside entities to help us in continuing a good pace on these investigations."
Ways said the number of health fraud convictions has increased steadily since 1992, the year the FBI "really started to get involved in these cases."
Because the investigations usually take three or four years to reach trial, the number of convictions rose sharply in 1996 and 1997. The number dropped slightly in 1998, when many of the agents assigned to health fraud were "tied up in trial" and thus unable to pursue any other investigations, says Ways. "But I think in FY 1999 we’re looking at . . . an upward spiral of convictions."
Meanwhile, Medicare audits show a dramatic decline in overpayments.
The FBI could see its future caseload drop, based on the results of a Feb. 9 Office of the Inspector General (OIG) report showing that improper Medicare payments to hospitals, doctors, and other health care providers declined dramatically last year to the lowest error rate since the government began performing such comprehensive audits three years ago.
The OIG estimates Medicare’s payment error rate for fiscal year 1998 was 7.1%, representing $12.6 billion in improper payments. This compares with an error rate of 11% in FY 1997, representing an estimated $20.3 billion in overpayments, and 14% in FY 1996, accounting for an estimated $23.2 billion in improper payments. These improper payments ranged from inadvertent mistakes to outright fraud and abuse. However, the OIG could not identify how much of the error rate is attri butable to actual fraud.
In contrast, a General Accounting Office study released just before the OIG’s report credited the decline in improper Medicare billing by physicians and others to better documentation supplied by providers to auditors, rather than a reductions in improper payments.
The major problem areas with improper Medicare claims as identified by the GAO were:
• billing for services that were not medically necessary;
• upcoding services to secure a higher-than-justified reimbursement rate;
• poor and incorrect documentation;
• billing for services not covered by Medicare.
Hospitals, physicians, and home health agencies accounted for more than 77% of the improper payments. Of this, hospitals were responsible for 39% of erroneous claims, physicians accounted for 26%, and home health’s share was almost 13%. The rest of the improper payments, in order of magnitude, were attributed to nursing facilities, non-prospective payment system hospitals, laboratories, end stage renal disease centers, ambulance companies, ambulatory surgical centers, durable medical equipment suppliers, and hospices.
In FY 1998, Medicare served some 39 million beneficiaries paying $210 billion in benefit claims, including about $33 billion in managed care expenditures. More than 860 million claims were processed during that time.
"The Inspector General’s report is welcome proof that our zero tolerance policy against waste, fraud and abuse is paying off," HHS Secretary Donna E. Shalala said in a statement. "We still have a big job to do in eliminating improper Medicare payments, but with a 45% reduction in improper payments in just two years, we are making real progress."
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