Tuesday, May 13, 2014


 Dianne De La Mare

The US General Accounting Office (GAO) recently released a report, Medicare Fraud: Progress Made, but More Action Needed to Address Medicare Fraud, Waste and Abuse.  This report considers the progress that the Centers for Medicare & Medicaid (CMS) has made in implementing key strategies previously recommended to protect the Medicare program from fraud but also determines what actions CMS must still take to make improvements.

The report discusses that the Affordable Care Act (ACA) authorized, and CMS has implemented, actions to strengthen provider enrollment that addresses past weaknesses identified by both GAO and HHS, Office of Inspector General (OIG). For example, CMS has hired contractors to determine whether providers and suppliers have valid licenses and are at legitimate locations. CMS also recently contracted for fingerprint-based criminal history checks for high-risk providers and suppliers. CMS could, according to the report, further strengthen provider enrollment by issuing a rule to require additional provider and supplier disclosures of information and establishing core elements for provider and supplier compliance programs.

The report also discusses how Medicare uses prepayment review to deny claims that should not be paid and postpayment review to recover improperly paid claims. The report finds that increased use of prepayment edits could help prevent improper Medicare payments. For example, prior GAO work identified millions of dollars of payments inconsistent with selected coverage and payment policies and therefore improper. Postpayment reviews are also critical to identifying and recouping payments. GAO recommended better oversight of both the information systems analysts use to identify claims for postpayment review, in a 2011 report, and the contractors responsible for these reviews, in a 2013 report. CMS has addressed some of these recommendations, but not all, according to the current report.

Lastly, having mechanisms in place to resolve vulnerabilities that could lead to improper payments is critical to effective program management and could help address fraud. However, GAO work has shown weaknesses in CMS's processes to address such vulnerabilities, placing the Medicare program and its beneficiaries at risk.

For example, GAO has made multiple recommendations to CMS to remove Social Security numbers from beneficiaries' Medicare cards to help prevent identity theft, and, while HHS agreed with these recommendations, the department also reported that CMS could not proceed with the changes for a variety of reasons, including funding limitations. The report states that to date, CMS has not taken action on these recommendations. CLICK HERE to obtain a copy of the complete GAO report.

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