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Feds Will Continue Focus on Healthcare Fraud
Although the Bush Administraton seems committed to cutting "Big Government," don't expect a turn-around in the federal government's pursuit of Medicare fraud. Experts say ASCs and other healthcare providers should assume that plenty of resources will remain available for Medicare audits.
"There are no indications that this administration is going to back off," says Dennis Jay, executive director of the Coalition Against Insurance Fraud, a consortium of government agencies, insurance companies and consumer groups.
Two recent reports from the Office of Inspector General support this observation. One states that OIG will boost its 2001 target for "return on investment" (dollars recovered as a result of dollars spent on Medicare audits and investigations) by 39 percent. Another OIG report says "vigilance is needed" because certain overpayment problems "have persisted for the past five years."
Since 1992, U.S. attorneys have quadrupled the rate of criminal healthcare fraud investigations. Over the last five years, healthcare fraud has become one of the most active areas in federal prosecutor's offices all over the country, from Boston, where a single case netted $486 million, to Florida, where prosecutors are particularly aggressive.
OIG estimates that in 2000, Medicare overpaid $11.9 billion (6.8 percent of all fee submissions).
"These improper payments could range from inadvertent mistakes to outright fraud and abuse. We cannot quantify what portion of the error rate is attributable to fraud," notes Michael F. Mangano, HCFA's Acting Inspector General.
In 1999, OIG recovered nearly $408 million in fines from healthcare facilities and providers investigated for fraud, and excluded 2,976 providers and facilities from future participation in Medicare. There were 401 criminal convictions and 541 civil actions.
Experts are quick to point out, however, that most Medicare audits turn up errors rather than fraud or abuse.
"Fraud is a big deal. Medicare doesn't enter an accusation of fraud lightly," notes Donna McCune, CSS-P, COE, senior consultant with Corcoran Consulting Group, San Bernardino, Calif.
It's more likely that, if a provider is found to have received "improper payments," they were due to mistakes. The OIG says the majority of billing errors are for:
Coding errors. The vast majority of these errors are made by physician offices.
Because the majority of "improper payments" are for mistakes rather than fraud, some see the government's hand as too heavy and warn that well-meaning healthcare providers may get unfairly snagged.
"The government believes there is an element of crime in our healthcare system," says Keith M. Korenchuk, a healthcare lawyer in Charlotte, N.C. "But a vast majority of healthcare centers are trying the best they can and don't understand the amazing complexity of these billing procedures. The government is creating a climate of fear."
There has been bipartisan support for the Medicare Education and Regulatory Fairness Act, to be introduced this summer. The bill limits pre- and post-payment audit actions and offering providers more opportunities to learn correct billing practices.
"This bill will put an end to the idea of providers being guilty until proven innocent. MERFA is good for providers, it's good for their patients and it's good for the Medicare system," says Cathy Cohen, of the American Academy of Ophthalmology, one of many groups that support the bill.
In the meantime, the best defense is a good offense, Medicare experts say. Consultants like certified coding specialist Lolita Jones, RHIA, CCS, say they've received more requests for internal coding audits that might turn up errors before they ever reach auditors. Others urge administrators to develop a good compliance plan, and make sure coders know their stuff.
"You have to have a compliance plan," says Ms. McCune. "You also have to make sure your people know what they're doing. Send them to coding seminars and encourage ongoing coding education. It's money and time very, very well spent."
Although the Bush Administraton seems committed to cutting "Big Government," don't expect a turn-around in the federal government's pursuit of Medicare fraud. Experts say ASCs and other healthcare providers should assume that plenty of resources will remain available for Medicare audits.
"There are no indications that this administration is going to back off," says Dennis Jay, executive director of the Coalition Against Insurance Fraud, a consortium of government agencies, insurance companies and consumer groups.
Two recent reports from the Office of Inspector General support this observation. One states that OIG will boost its 2001 target for "return on investment" (dollars recovered as a result of dollars spent on Medicare audits and investigations) by 39 percent. Another OIG report says "vigilance is needed" because certain overpayment problems "have persisted for the past five years."
Since 1992, U.S. attorneys have quadrupled the rate of criminal healthcare fraud investigations. Over the last five years, healthcare fraud has become one of the most active areas in federal prosecutor's offices all over the country, from Boston, where a single case netted $486 million, to Florida, where prosecutors are particularly aggressive.
OIG estimates that in 2000, Medicare overpaid $11.9 billion (6.8 percent of all fee submissions).
"These improper payments could range from inadvertent mistakes to outright fraud and abuse. We cannot quantify what portion of the error rate is attributable to fraud," notes Michael F. Mangano, HCFA's Acting Inspector General.
In 1999, OIG recovered nearly $408 million in fines from healthcare facilities and providers investigated for fraud, and excluded 2,976 providers and facilities from future participation in Medicare. There were 401 criminal convictions and 541 civil actions.
Experts are quick to point out, however, that most Medicare audits turn up errors rather than fraud or abuse.
"Fraud is a big deal. Medicare doesn't enter an accusation of fraud lightly," notes Donna McCune, CSS-P, COE, senior consultant with Corcoran Consulting Group, San Bernardino, Calif.
It's more likely that, if a provider is found to have received "improper payments," they were due to mistakes. The OIG says the majority of billing errors are for:
- Unsupported services. Medicare considers services unsupported when there is no documentation to support the diagnosis, or insufficient diagnosis. This mistake is most likely to be made by ASCs.
- Medically unnecessary services. In these cases, there's enough documentation for the claim, but it indicates to Medicare auditors that the services were not medically justified. This error is most often made by hospitals.
Coding errors. The vast majority of these errors are made by physician offices.
Because the majority of "improper payments" are for mistakes rather than fraud, some see the government's hand as too heavy and warn that well-meaning healthcare providers may get unfairly snagged.
"The government believes there is an element of crime in our healthcare system," says Keith M. Korenchuk, a healthcare lawyer in Charlotte, N.C. "But a vast majority of healthcare centers are trying the best they can and don't understand the amazing complexity of these billing procedures. The government is creating a climate of fear."
There has been bipartisan support for the Medicare Education and Regulatory Fairness Act, to be introduced this summer. The bill limits pre- and post-payment audit actions and offering providers more opportunities to learn correct billing practices.
"This bill will put an end to the idea of providers being guilty until proven innocent. MERFA is good for providers, it's good for their patients and it's good for the Medicare system," says Cathy Cohen, of the American Academy of Ophthalmology, one of many groups that support the bill.
In the meantime, the best defense is a good offense, Medicare experts say. Consultants like certified coding specialist Lolita Jones, RHIA, CCS, say they've received more requests for internal coding audits that might turn up errors before they ever reach auditors. Others urge administrators to develop a good compliance plan, and make sure coders know their stuff.
"You have to have a compliance plan," says Ms. McCune. "You also have to make sure your people know what they're doing. Send them to coding seminars and encourage ongoing coding education. It's money and time very, very well spent."
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