HHS Officials Explain $47.9B in Improper Medicare Payments

John Commins, for HealthLeaders Media , July 29, 2011

Daly said her office has identified five strategies to help reduce fraud, waste, and abuse, and halt improper Medicare payments.  Not all have yet been acted upon:  

1.)   Strengthen provider enrollment standards and procedures. Strong standards and procedures can help reduce the risk of enrolling sham providers. CMS has implemented provisions of the Patient Protection and Affordable Care Act that screen providers by levels of risk and provide a stringent review of high-risk providers, but has yet to implement certain GAO recommendations in this area.

2.)    Improve prepayment reviews. Prepayment reviews of claims help ensure that Medicare pays correctly the first time. As of July 1, 2011, CMS has begun applying predictive modeling analysis to claims and plans to expand Medicare prepayment controls. CMS has not implemented GAO's recommendation to improve prepayment reviews.

3.)   Focus post-payment reviews on vulnerable areas. Post-payment reviews are critical to identifying payment errors and recouping overpayments. In March 2009, CMS began instituting a national recovery audit contractor program to help the agency supplement its post-payment reviews. CMS has also developed information technology to help it better identify claims paid in error, but GAO recently reported that the systems are not being used to the extent originally planned and made several recommendations to address the issues.

4.)   Improve oversight of contractors. CMS has taken action to improve oversight of prescription drug plan sponsors' fraud and abuse programs, which addresses GAO's recommendation, but is still developing specific performance statistics.

5.)   Develop process to address identified vulnerabilities. CMS has not developed a robust corrective action process for vulnerabilities identified by Medicare RACs as GAO recommended.

See Also:

OIG: Medicare Advantage Prepayments Cost CMS Millions


John Commins is a senior editor with HealthLeaders Media.

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1 comments on "HHS Officials Explain $47.9B in Improper Medicare Payments"

Dawn Smith (8/8/2011 at 12:26 PM)
Just graduating from a medical office specialist course, I had the opportunity to have classes that included patient billing and we briefly learned about billing and coding. Can I just say what a mess that system is! I cannot believe how many codes there are and having to [INVALID] them on a yearly basis. It's a wonder that there are so many mistakes. And why in these departments aren't questions being asked if one's not sure of how to bill a patient? There's got to be someone held accountable for such mistakes. It is out of control and ridiculous. Let's slow down a bit people and take the time to do the job right the first time!!!! Where's the support in these departments? Something's got to change and change like yesterday! Start cracking the whip supervisor's!!! The problem with some people is that they are there to punch in and punch out. There is no compassion for what they do in there jobs. There is no one there to stand up and call someone out on their poor behavior. Having people's treatments be eligible or not, to some can mean financial disaster. We are all trusting in our clinics/hospitals to have competent people do their jobs correctly so we don't have to worry about our visit(s). Lets take pride in our positions and if you can't, then get out of the business!




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