Senators release ideas to combat Medicare/Medicaid waste, fraud, and abuse

Posted on February 4, 2013 | No Comments
Filed under 113th Congress, Congressional Action, Fraud and Abuse

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Last week, six current and former members of the Senate Finance Committee, led by Ranking Member Orrin Hatch (R-Utah) and Chairman Max Baucus (D-Mont.), released a report outlining recommendations from stakeholders in the health care community regarding potential opportunities to improve federal efforts to combat waste, fraud, and abuse in the Medicare and Medicaid programs. The other four report authors include Senators Tom Coburn (R-Okla.), Ron Wyden (D-Ore.), Chuck Grassley (R-Iowa), and Tom Carper (D-Del.). Last May, the bipartisan group of lawmakers invited stakeholders to submit white papers offering recommendations and innovative solutions to improve program integrity efforts, strengthen payment reforms, and enhance fraud and abuse enforcement efforts. The resulting report highlights a number of submitted proposals and recommendations.

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GAO report explores health care fraud

October 9, 2012

The Government Accountability Office (GAO) has designated Medicare and Medicaid as high-risk programs partly because their size and complexity make them vulnerable to fraud. GAO was asked to provide information on the types of providers that are the subjects of fraud cases. The resulting GAO report identifies provider types who were the subjects of fraud cases in (1) Medicare, Medicaid, and CHIP that were handled by federal agencies, and changes in the types of providers in 2005 and 2010; and (2) Medicaid and CHIP fraud cases that were handled by Medicaid Fraud Control Units (MFCUs). To identify subjects of fraud cases handled by federal agencies, GAO combined data from three agency databases and removed duplicate subject data. GAO also reviewed public court records, such as indictments, to identify subjects’ provider types. To describe providers involved in fraud cases handled by the MFCUs, GAO collected aggregate data from 10 state MFCUs, which represented the majority of fraud investigations, indictments, and convictions nationwide. According to data GAO collected from 10 state Medicaid Fraud Control Units (MFCU), over 40 percent of the 2,742 subjects investigated for health care fraud in Medicaid and CHIP in 2010 were home health care providers and health care practitioners. Of the criminal cases pursued by these MFCUs, home health care providers comprised nearly 40 percent of criminal convictions and 45 percent of subjects sentenced in 2010. Civil health care fraud cases pursued by these MFCUs in 2010 resulted in judgments and settlements totaling nearly $829 million. Pharmaceutical manufacturers were to pay more than 60 percent ($509 million) of the total amount of civil judgments and settlements.

CMS releases final rule addressing Medicare fraud

April 24, 2012

The Centers for Medicare & Medicaid Services (CMS) published a final rule today addressing three provisions under the Affordable Care Act (ACA): 1) Medicare and Medicaid Programs; 2) Changes in Provider and Supplier Enrollment, Ordering and Referring, and Documentation Requirements; and 3) Changes in Provider Agreements. This final rule follows up on the May 5, 2010 interim final rule with comment period. It requires all providers of medical or other items or services and suppliers that qualify for a National Provider Identifier (NPI) to include their NPI on all applications to enroll in the Medicare and Medicaid programs and on all claims for payment submitted under the Medicare and Medicaid programs. In addition, it requires physicians and other professionals who are permitted to order and certify covered items and services for Medicare beneficiaries to be enrolled in Medicare. Finally, it mandates document retention and provision requirements on providers and supplier that order and certify items and services for Medicare beneficiaries. The final rule intends to prevent fraud in Medicare...

HHS/DOJ issue annual report on fraud and abuse

January 25, 2011

The U.S. Department of Health and Human Services (HHS) and the U.S. Department of Justice (DOJ) have issued their annual report on health care fraud and abuse. The report shows that the Federal Government's Health Care Fraud and Abuse Control Program recovered more than $4 billion of taxpayer dollars during fiscal year 2010. HHS Secretary Kathleen Sebelius said, "Thanks to the President’s leadership and the new tools provided by the Affordable Care Act, we can focus on stopping fraud before it happens."

CMS grants $9 million to combat fraud

October 1, 2010

The Centers for Medicare and Medicaid Services has granted $9 million to support more than 50 Senior Medicare Patrol (SMP) Programs fight fraud. According to the agency, "The grants will provide additional funds to increase awareness of Medicare and Medicaid beneficiaries of health care fraud prevention, identification and reporting through expansion of SMP program capacity."

HHS issues proposed rule to stem Medicare, Medicaid, and CHIP fraud

September 21, 2010

The Department of Health and Human Services has issued a proposed rule to stem fraud in the Medicare, Medicaid, and Children's Health Insurance Program under authority created by the health reform law. According to the agency, the proposed rule will:

"Establish the requirements for suspending payments to providers and suppliers based on credible allegations of fraud in Medicare and Medicaid;
"Establish the authority for imposing a temporary moratorium on Medicare, Medicaid, and CHIP enrollment on providers and suppliers when necessary to help prevent or fight fraud, waste, and abuse without impeding beneficiaries’ access to care.
"Strengthen and build on current provider enrollment and screening procedures to more accurately assure that fraudulent providers are not gaming the system and that only qualified health care providers and suppliers are allowed to enroll in and bill Medicare, Medicaid and CHIP;
"Outline requirements for states to terminate providers from Medicaid and CHIP when they have been terminated by Medicare or by another state Medicaid program or CHIP;
"Solicit input on how to best structure and develop provider compliance programs, now required under the Affordable Care Act, that will ensure providers are aware of and comply with CMS program requirements."

Health agencies launch fraud prevention education campaign

June 8, 2010

The Department of Health and Human Services, Centers for Medicare and Medicaid Services, and Administration on Aging have launched a one million-dollar public-education campaign to combat fraud timed to coincide with the issuing of $250 "donut hole rebate" checks created by the health reform law. This includes radio ads in English, Spanish, Korean, and Armenian.

HHS and DOJ send letter to combat Medicare fraud

June 8, 2010

Health and Human Services Secretary Kathleen Sebelius and Attorney General Eric Holder have sent a letter to state attorneys general on new efforts to combat Medicare fraud. The letter is timed to coincide with the mailing of the $250 "donut hole rebate checks" authorized by the health reform law and pledges to "use the new tools and resources provided by the Affordable Care Act to further crack down on fraud."

HHS & DOJ highlight new anti-fraud provisions in health reform law

May 13, 2010

Releasing an annual report on health care fraud prevention, the Department of Health and Human Services and the Department of Justice emphasize new measures of the health reform law designed to route out abuse of the system.

Fraud and Abuse: Revisions to Anti-Kickback Statute

May 20, 2010

The health reform law revises the anti-kickback statute to broaden the reach of the law and enhance enforcement.