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Medicare Strengthens Anti-Fraud Program
By
Michael A. Piekarz
Spectrum Staff Writer
The
Centers for Medicare & Medicaid Services (CMS) has announced
an aggressive plan to locate and prevent waste, fraud and abuse in
the Medicare system as it
continues its efforts to preserve Medicare assets.
In 2007, it was estimated that fraud costs Medicare nearly $60 billion a year.
The unchecked thefts have drawn criticism from congressional leaders and other
government officials who have demanded that action be taken to curb losses to
the financially strapped program.
“Because Medicare pays for medical services and items without looking behind
every claim, the potential for waste, fraud and abuse is high,” explained
CMS Acting Administrator Kerry Weems.
The considerable amount of fraud has sparked a national outrage along with a
concerted effort to locate and prosecute those who attempt to bilk the system.
It also resulted in a series of protective measures being taken by CMS to help
eliminate fraudulent Medicare billings.
The latest anti-fraud efforts include the creation of the national Recovery Audit
Contractor (RAC) program.
Recovery Audit Contractors look at billing trends and patterns across Medicare
and focus on companies and individuals whose billings for Medicare services are
higher than the majority of providers and suppliers in that community.
Recovery Audit Contractors will also review paid claims for all Medicare Part
A and B providers to ensure that their claims meet Medicare’s statutory,
regulatory and policy requirements and regulations.
If the RACs find that any Medicare claim was incorrectly paid, they’ll
resolve the issue. If a claim was overpayed, they will request repayment from
the provider. If a claim was underpaid, they’ll ensure the provider is
repaid.
In order to keep costs down, RACs will be paid on a contingency fee basis on
both the overpayments and underpayments they find. One Recovery Audit Contractor
collected over $900 million in overpayments and nearly $38 million in underpayments.
CMS has also consolidated its fraud detection efforts, increased its oversight
of medical equipment suppliers and is encouraging cooperation with beneficiaries
and health care providers.
“By enhancing our oversight efforts, we can better ensure that Medicare
dollars are being used to pay for equipment or services that beneficiaries actually
received while protecting them and the Medicare trust fund from unscrupulous
providers and suppliers,” said Weems.
CMS’s work with beneficiaries will include ensuring that they received
the durable medical equipment or home health services for which Medicare was
billed and that the items or services were medically necessary.
One of the most common fraudulent schemes is the illicit billing for durable
medical equipment, prosthetics and orthotics (DMEPOS).
To fight DMEPOS fraud, CMS is taking additional steps in Florida, California,
Texas, Illinois, Michigan, North Carolina and New York to ensure the products
and services are delivered to Medicare beneficiaries as promised.
“We are continuing to build on our fraud fighting and program integrity
efforts by identifying high risk areas and trends to better focus our limited
funds and resources,” said Weems.
Medicare is required by law to pay claims to health care providers for services
provided to beneficiaries within 30 days after the claim is submitted.
After the claim is paid, CMS or its contractors will review the claim to ensure
that the items or services were actually provided and that the services were
medically necessary.
If the claim was not submitted under Medicare’s rules, CMS checks to see
if the claim was submitted in error or may be potentially fraudulent. Those claims
that could be fraudulent are referred to law enforcement for further investigation.
This page and its contents ©2008
Metropolitan News Company, Inc.
