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Posts tagged 'medicare audits'

Medicare Fraud Rate Higher than Originally Thought

It seems like Medicare continues to have more problems when it comes to keeping records, fraud and audits. We recently reported that there had been an inspection by the Inspector General’s office regarding overpayments, payments for false claims and fraud. That investigation, by the Human Services inspector general’s office originally uncovered what seemed to amount to about $700 million.

The Medicare Officials that conducted the investigation gave these figures. There is only one problem – the information was based on faulty statistics. In fact, the way that Medicare officials conducted the investigation went directly against Medicare rules.

What was supposed to happen was that the billing be matched against purchases, medical records and orders from doctors. They were not handled this way. They were matched against purchases, but limited medical records in only some of the cases and they were essentially not matched against orders from doctors at all. The end result is that many phony purchases were matched against phony billing, leaving much of the substantiating information out of the equation.

As a result of the way that this was handled (remember the fox watching the hen house), Medicare officials investigated their own information and came out with a faulty figure. They determined that the $700 million in fraud that they gave as their figure amounted to about a 7.5% fraud rate.

When looking at the true figures, however, it is actually estimated that the total amount in fraud is actually over $1 billion. The federal report said that if the Medicare officials had made the auditors abide by the rules, the amount of incorrect or fraudulent billing would have been much higher, resulting in the $1 billion mentioned.

With Medicare having the financial problems that we continue to hear about, $700 million was bad enough. Now we are looking at $1 billion. It seems that $1 billion would pay for a lot of prescriptions that the Medicare Advantage donut hole is swallowing up.

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Medicare Faces Fraud on Another Front

Reports have recently revealed that Medicare prescription drug supplements are not being watched very carefully. In fact, there is a fraud prevention program that is supposed to be in effect to deal with the prescription drug coverage offered by private insurance companies.

The Government Accountability Office holds CMS responsible for monitoring and auditing the $39 billion prescription drug programs. That is a great deal of money that could easily be misused. The GAO examined five plans that are unnamed and created a report detailing the shortcomings regarding what CMS is responsible for.

Some of the oversight responsibilities that have not been adhered to by CMS include establishing training programs for employees so that they can recognize fraud and misuse of relevant laws. Only two of the five programs have established such training.

CMS states that though they did not have the training in place, the programs did establish written standards for detection and prevention of fraud and waste. The GAO has strongly suggested that CMS should conduct audits of the prescription drug programs.

CMS says that they have asked the programs to produce self-assessments – (remember the fox watching the hen house, again?) – and said they would use the self-assessment surveys in place of audits for now. They said that they are focusing on complaints, especially since their audit budget was capped at $720 million, stating that this restricted amount makes it difficult, if not impossible, to conduct proper auditing.

This attitude toward auditing fraud, coupled with the fact that CMS has not developed even a streamlined auditing system, might be saving Medicare some tightly budgeted money in the short term, but the billions that are being taken out of Medicare while officials are ignoring the problem, could be saving the country and its Medicare beneficiaries billions. This might be enough to eliminate some of the unaffordable and superfluous supplemental programs and create a Medicare system that is affordable and works for everyone.

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Posts tagged 'medicare audits'

Medicare Fraud Rate Higher than Originally Thought

Medicare Faces Fraud on Another Front

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