Congressional Panel Once Again Reviewing Medicare Fraud

By Author: Georges Baxter
Total Articles: 15
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A recent Medicare report, “Program Remains at High Risk Because of Continuing Management Challenges,” found the federal government made about $48 billion in improper payments for Medicare and Medicare Advantage in fiscal year 2010. This doesn’t even include improper payments made through the Medicare Part D prescription drug benefit.

“The average citizen under the age of 65 keeps asking if there is going to be a Medicare program in place for them,” suggests Alan Weinstock an insurance broker at MedicareSupplementPlans.com. “It’s easy to understand why they might be skeptical and just a little fearful that they are paying into a system that will not pay them back.”

Government Accountability Office Delivers Report

The Medicare report delivered by the Government Accountability Office (GAO) indicates that the Medicare program is on a path that is “fiscally unsustainable over the long term.” The need for reform is evident. The desire to “achieve efficiency and savings” as well as “to improve its management, program integrity, and oversight of patient care and safety” is in the best ...
... interest of all concerned.

With that in mind the GAO made these suggestions:

1. Reform and refine payments. The report indicates that the Center for Medicare and Medicare Services (CMS)
has to implement reforms for Medicare Advantage, inpatient, and other services. However, more is waiting to be done.

2. Improve program management. The most recent step in improvement is through CMS’s new Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program. However, CMS still lacks program internal control over its management of contracts which has resulted in an increased risk of improper payments.

3. Enhance program integrity. Looking to curb overpayments for recoupment, CMS has implemented a national Recovery Audit Contractors (RAC) program. This program also is designed to set performance measures to reduce improper payments, establish regulations to tighten provider enrollment, and to create a Center for Program Integrity.

4. Oversee patient care and safety. Nursing home care has been under scrutiny in recent years; however, there is a fear that quality problems may be understated due to weaknesses in survey methodology. CMS is working to implement changes.

Ultimately, the GAO feels that the CMS needs to reform and refine Medicare’s payment methods to achieve efficiency and savings, and to improve its management, program integrity, and oversight of patient care and safety.

The GAO Indicates More Needs to be Done

According to the GAO, CMS has not met their criteria for removing Medicare from the High-Risk List. CMS needs a plan with clear measures and benchmarks for reducing Medicare’s risk for improper payments, inefficient payment methods, and issues in program management and patient care and safety.

The GAO suggests the CMS take these actions:

5. Implement an effective system for physician profiling

6. Manage payments for services more efficiently

7. Develop policies to improve oversight of program contracts

8. Review specific claims for services with high rates of improper billing

9. Supervise nursing homes with serious care problems

In the end, it will be up to CMS to develop an appropriate corrective action process to address vulnerabilities to improper payments that lead to Medicare fraud.

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