MEDICARE: Stepping Up Anti-Fraud Efforts
Health and Human Services Secretary Donna Shalala announced Tuesday that Medicare will begin hiring special contractors to fight fraud and abuse. Until now, only insurance companies -- whose primary responsibility is to process Medicare claims -- have been permitted to conduct audits, medical reviews and other activities that attack waste and fraud. The Health Insurance Portability and Accountability Act empowers HHS to include private sector experts who can bring "new energy and ideas to this essential task." Shalala said, "We are determined to drive out the scam artists who are stealing from the health care of seniors and the disabled." The proposed regulation sets guidelines for specific activities that anti-fraud inspectors may undertake "to protect Medicare and the taxpayers who fund it." These guidelines include medical procedure reviews, which ensure medical necessity, as well as cost report audits and secondary payer determinations which ensure Medicare is paying only for what it should. Also included are provider and beneficiary education explaining what can and cannot be billed to Medicare, and a list of durable medical equipment that require prior authorization before billing.
Further Improvements To Track Record
Anti-fraud measures saved Medicare over $7.5 billion in fiscal 1997. The highly successful Operation Restore Trust fraud detection pilot program returned $23 to the trust fund for every dollar spent on enforcement and collection. The department is applying lessons learned from the pilot nationwide. In addition, a pilot program in Florida uncovered significant abuse through a practice of reassigning physician billing numbers: some clinics were submitting claims under billing numbers of physicians who had not worked at their clinics in more than two years, while other submitted claims were for care provided by a single physician in a single day at clinics hundreds of miles apart. Shalala said that while the department "set records for convictions, collections and kicking bad providers out of our programs in 1997 ... we can and must do more" (HCFA release, 3/17).