Medicare steps up fraud and abuse efforts
In a new wrinkle in the government's ongoing fraud and abuse campaign, Medicare will begin hiring anti-fraud contractors. That's the word from the U.S. Department of Health and Human Services (HHS), the agency in Washington, DC, that oversees the Medicare program.
Medicare saved more than $7.5 billion through fraud and abuse investigations in fiscal year 1997, the government says. In conjunction with law enforcement partners, another $1 billion was returned to the Medicare Trust Fund. Efforts of the highly-publicized Operation Restore Trust anti-fraud program identified $23 in money owed the Trust Fund for every $1 spent on fraud detection and recoveries.
Until now, only insurance companies whose primary responsibility is to process Medicare claims have been able to conduct audits, medical reviews, and other activities that attack waste, fraud, and abuse, according to HHS. Under new authority provided by the Health Insurance Portability and Accountability Act, Medicare is expanding its contracting authority to include more firms from the private sector that can bring new energy and ideas to the fraud-fighting task.
A new proposed regulation, published in the Federal Register, sets parameters for specific activities that special anti-fraud contractors can undertake to protect Medicare and the taxpayers who fund it. Activities include:
1. medical reviews to ensure services billed to Medicare were medically necessary;
2. cost report audits to ensure Medicare only pays for services and overhead costs it is legally obligated to pay;
3. secondary payer determinations to ensure Medicare does not pay bills for Medicare beneficiaries that should be paid by another insurer;
4. provider and beneficiary education about what can and can't be billed to Medicare and how to spot and report potential fraud and abuse;
5. medical equipment, such as wheel chairs, that require authorization before billing to Medicare.
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