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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™


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.


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!


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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14 Responses

  1. Dr. Marcinko,

    I agree completely with you. We need to enforce and execute the laws and policies we already have on the books. Many thanks for stating the obvious.



  2. Jane and Dr. Marcinko

    DATELINE: Secretary Sebelius says that Medicare claims fraud outpaced fixes

    Consolidating claims databases and discerning suspicious patterns in healthcare billing are technical solutions that federal officials are beginning to use to attack Medicare fraud.


    Did you say beginning to … well done Kathy, duh!



  3. CMS Enrollment Compliance to Increase

    CMS’s intense focus on enrollment compliance will turn increasingly to hospitals, physicians, and other Part A and B providers and suppliers now that the agency has put controls in place to keep undeserving durable medical equipment (DME) companies out of Medicare.

    The director of Medicare program integrity said April 18, “There is no more important program-integrity function on the Medicare side than enrollment.” Kim Brandt asserted at the Health Care Compliance Assn. Compliance Institute in Dallas that once there are bad apples in Medicare, “it’s really hard to get them out.”

    The Medicare integrity group also monitors providers and suppliers to ensure that they are paid only for those items they are licensed to provide. For example, effective Jan. 3, 2011, Medicare will not pay for DME unless the ordering physician is enrolled in Medicare through PECOS, which is CMS’s Internet-based enrollment system. DME claims will be rejected if ordering physicians and non-physician practitioners are not in PECOS, which stands for Provider Enrollment, Chain and Ownership System.

    Source: Nina Youngstrom, Report on Medicare Compliance [5/7/10}


  4. Top 5 GAO Ways to Prevent Fraud

    The Government Accountability Office has identified five key areas for preventing Medicare fraud, waste and abuse.




  5. Reform Law Includes Large New Fraud Enforcement Powers

    Some of the least publicized but perhaps most far-reaching provisions of the new health reform law relate to fraud-and-abuse enforcement. The law grants the federal government dramatic new powers — many of them not clearly defined or in partial conflict with other statutes — to pursue both providers and health plans.

    For example, one provision in the law states that Medicare and Medicaid payments may be suspended “pending an investigation of a credible allegation of fraud against the provider of services or supplier” unless the HHS secretary determines there is a good reason not to suspend the payments. The statute directs the HHS secretary to consult with the department’s Office of Inspector General to determine if there is such a credible allegation of fraud, but there is no definition of “credible allegation” in the law, notes Carrie Valiant, a partner in EpsteinBeckerGreen. .

    Source: James Gutman, AIS’s Health Reform Week, [8/3/10]


  6. More on Healthcare Fraud

    A former chief financial officer of three different hospital networks is facing federal fraud charges for allegedly stealing more than $200,000 from health systems in Connecticut and Ohio.




  7. Federal Government Expands Grassroots Fraud Prevention Effort

    The Centers for Medicare & Medicaid Services (CMS) today announced the award of $9 million in grants to help more than 50 Senior Medicare Patrol (SMP) programs fight Medicare fraud. This is part of President Obama’s mandate to educate seniors and other Medicare beneficiaries about how to prevent fraud in Medicare.

    The announcement to double the funding for SMP activities states that the grants will provide additional funds to increase awareness of Medicare and Medicaid beneficiaries of healthcare fraud prevention, identification, and reporting through expansion of SMP program capacity. Increased funding levels for states identified with high-fraud areas will support additional targeted strategies for collaboration, media outreach, and referrals. The Administration on Aging will administer these grants in partnership with CMS.

    Source: CMS

    So, be not so skeptical Dr. Marcinko!



  8. Feds Break up $200 Million Medicare Scam

    Dr. Marcinko – to the contrary:

    In yet another prosecution intended to deflate the notion that South Florida is a “haven” for Medicare fraud, federal authorities broke up a $200 million operation that they say was claiming, among other allegations, to have provided psychological counseling services to Alzheimer’s patients. The 13-count indictment charges four individuals and two businesses with paying kickbacks to other Medicare providers and patients in exchange for providing billing information and making it appear that patients were eligible to receive counseling services when they were not.

    The services were either not medically necessary or never provided at all. For example, American Therapeutic Corp. routinely claimed to have provided intensive mental illness treatments to patients whose dementia and diminished mental capacity would not have allowed them to benefit from psychological counseling. “Today’s arrests and search warrants give notice to anyone involved in fraudulent healthcare practices that there are no ‘safe havens’ for their businesses in South Florida,” FBI acting special agent in charge William Maddalena said in a news release.

    Source: Joe Carlson, Modern Healthcare [10/21/10]


  9. Healthcare Fraud Prosecutions on Pace to Rise 85%

    New government statistics show federal healthcare fraud prosecutions in the first eight months of 2011 are on pace to rise 85% over last year due in large part to ramped-up enforcement efforts under the Obama administration.

    The statistics, released by the non-partisan Transactional Records Access Clearinghouse (TRAC), show 903 prosecutions so far this year. That’s a 24% increase over the total for all of fiscal year 2010, when 731 people were prosecuted for health fraud through federal agencies across the country. Prosecutions have gone up 71% from five years ago, according to TRAC.

    Source: Kelly Kennedy, USA Today [8/29/11]


  10. Nearly All Physicians Must Revalidate Medicare Enrollment by 2013

    Roughly 750,000 physicians in the Medicare program soon will be asked to revalidate their individual enrollment records during a massive anti-fraud effort required by the health system reform law. The Centers for Medicare & Medicaid Services hopes to weed out only the people who shouldn’t have billing privileges, but physicians are concerned that legitimate health professionals could get caught up in the enrollment sweep by mistake.

    CMS gradually will send revalidation requests by mail to more than 1.4 million health professionals — more than half of whom are doctors — between now and March 23, 2013, the agency announced on Aug. 10. Physicians who have enrolled since March 25, 2011, will not be required to revalidate, because their applications were scrutinized under new screening criteria, CMS said.

    Source: Charles Fiegl, AMNews [8/29/11]


  11. HHS Warns of Fraud Liability in Re-Assigned Medicare Numbers

    Federal investigators are warning physicians who allow healthcare firms to use their Medicare provider numbers that the doctors can be held liable for any fraudulent bills the firms submit on their behalf. Physicians can legally re-assign their Medicare payments from the CMS to outside organizations by filling out Form CMS-855R. However, HHS’ inspector general’s office is warning physicians to use “heightened scrutiny” to ensure that the entities receiving their payments are legitimate providers or suppliers of healthcare items and services.

    The warning to Medicare doctors was prompted by a spate of eight settlements in which physicians were accused of violating the Civil Monetary Penalties Law after re-assigning their Medicare provider numbers to the firms in exchange for receiving medical directorships with the companies, the OIG Alert from HHS’ inspector general’s office said. “We thought it might be helpful to remind physicians to exercise caution when re-assigning Medicare payments,” an inspector general’s office spokesman said.

    Source: Joe Carlson, Modern Physician [2/18/12]


  12. CMS to Revamp Money Losing Anti-Fraud Programs

    The CMS is restructuring two large anti-fraud programs in healthcare, in part, because they have cost more to implement than they have returned to the federal government. Dr. Peter Budetti, director of the Center for Program Integrity at the CMS, said in an interview following a congressional hearing on federal healthcare fraud-control efforts that improvements are under way in both the Medicaid Integrity Contractors Program and the so-called Medi-Medi claims analysis program.

    Budetti’s comments followed criticism of the programs during Tuesday’s hearing by Sen. Tom Coburn (R-OK), who criticized the Medi-Medi program for costing about $60 million while recovering only $57.8 million in 2007 and 2008, according to a recent federal audit. Similarly, the Medicaid contractors recouped less than what was spent on them. In March, the inspector general reported the contractors identified $6.9 million in overpayments for six months of the year in which the CMS paid them $30.5 million.

    Source: Rich Daly, Modern Healthcare [4/24/12]


  13. Feds Announce New Anti-fraud Initiative

    HHS and the U.S. Justice Department have partnered with about a half-dozen health insurers to help prevent fraud and abuse in healthcare billing. The initiative is designed to share information on specific schemes, billing codes, and even geographical hotspots that have been used in fraudulent activity. The government hopes, for example, to be able to immediately detect when payments are billed for the same patient in two different cities on the same day.

    The initiative will use advanced technology and data analytics to identify when and where healthcare fraud is occurring, according to an HHS news release. Trade group America’s Health Insurance Plans is participating in the partnership with the Blue Cross and Blue Shield Association as well as health plans including Humana, UnitedHealth Group, and WellPoint. A total of 21 groups, representing federal, state, and private payers have signed on so far. The healthcare law sets stricter penalties – such as longer sentences – for cases with damages over $1 million—and allows for enhanced screenings of and suspended payments to providers or suppliers who are suspected of fraudulent activity.

    Source: Beth Kutscher
    Modern Healthcare [7/26/12]


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