A Skeptical View of the ‘National Summit on Health Care Fraud’

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Seeking Real Results; not Empty Rhetoric

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

All our ME-P readers and subscribers are aware of the ‘National Summit on Health Care Fraud’, at the National Institutes of Health (NIH), held on January 28, 2010 in Bethesda, Maryland. The much publicized summit discussed ways to eliminate fraud, waste and abuse in the US health care system.

A major speaker, of course, was US Secretary of Health and Human Services [DHSS] Kathleen Sebelius.

In My Opinion

IMHO, the summit was more political posturing and “nibbling at the margins”, than innovative thought leadership. Much like a hawkish politician with a platform against crime; who can argue with the proposition?

But, how do we actually reduce fraud and abuse? In other words, how can we achieve real results, and not just more anti-fraud rhetoric?

Here are two considerations, currently on the books, that need hard enforcement:

1. Medicare Integrity Program

The MP-P allows the DHHS to contract with non-governmental organizations, known as Medicare Program Safeguard Contractors, to carry out fraud and abuse detection, cost report audits, utilization review, provider payment determinations, and provider education, and to create a list of durable medical equipment subject to prior authorization for reimbursement.

Under this program, the Centers for Medicare and Medicaid Services (CMS) must implement regulations for contracting procedures.

2. Beneficiary Incentive Program

Under the BIP, Medicare beneficiaries are encouraged to report any suspicious billing activities. When a claim results in collection of funds of at least $100, the beneficiary may be paid a portion of the collections, up to $1,000 for each occurrence. Since this process does not require the same amount of time and resources associated with whistleblowing actions, there has been activity generated by senior groups leading to various enforcement actions.

This program has allowed the Medicare carriers to send notices to patients, which encourages them to call, report, and possibly be rewarded if the report results in action.

Assessment

The first step in fighting healthcare fraud and abuse is to know which laws apply in specific cases.

The next step is formulating policies and procedures to ensure that all workforce members understand how to comply and what their individual responsibilities are in maintaining a sound healthcare business organization.

The third step is enforcement and punishment; less talk and more action!

Assessment

The most effective way to accomplish all of this is through the implementation of a medical practice compliance program, and more specifically, the augmentation of the above two programs currently in existence.

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Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

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