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Understanding the Spoils of Healthcare Fraud and Abuse

6 Responses

1. Barbara, on June 5, 2013 at 2:10 PM said:

   WOW!

   A picture really is worth a thousand words – or bucks!

   Barbara

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2. Ann Miller RN MHA, on June 26, 2013 at 12:22 AM said:

   Doctor-Specific Medicare Claims Data Could be Released

   For decades, the CMS has kept secret its records on Medicare claims payments to individual physicians. But Justice Department statements in a recent lawsuit and the first-ever releases of other provider charge data this year suggest the federal government’s position on keeping doctor-specific information secret may be changing.

   Proponents of releasing the data say it could help identify patterns of waste and fraud and help patients and insurance companies find doctors who deliver the most efficient and highest quality care.

   But, medical groups have successfully fought to keep the payment information secret, saying it would violate physicians’ privacy rights to disclose their Medicare claims data.

   Source: Joe Carlson, modernhealthcare.com [6/25/13]

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3. Kim, on January 27, 2014 at 5:44 PM said:

   Obama Cracks Down on Docs Abusing Medicare

   Agree with the above – The Obama administration is cracking down on doctors who repeatedly overcharge Medicare patients, and for the first time in more than 30 years the government may disclose how much is paid to individual doctors treating Medicare patients.

   Kim

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4. Barbara, on July 1, 2014 at 6:03 PM said:

   CMS Fraud Prevention System Identification of Improper Medicare Payments

   In its second year of operations, CMS’ state-of-the-art Fraud Prevention System, that employs advanced predictive analytics, identified or prevented more than $210 million in improper Medicare fee-for-service payments, double the previous year. It also resulted in CMS taking action against 938 providers and suppliers.

   The Fraud Prevention System is used as part of an agency focus on home health services in South Florida. CMS identified this type of service in South Florida as an area of high risk to our programs. The Fraud Prevention System led to investigations and administrative actions, which ultimately led to the revocation of the billing privileges of home health agencies, with potential savings worth more than $26 million.

   
   Source: Centers for Medicare & Medicaid Services

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5. Fred, on July 16, 2014 at 11:48 AM said:

   Crowd sourcing fraud detection

   Medicare and Medicaid have active fraud detection units that are setting records for recoveries. The HHS effort is not entirely in-house, but also partners with insurance companies and other stakeholders to detect fraud.

   Click to access 589681.pdf

   And yet, the programs suffer billions in “improper payments.”

   Fred

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6. Hope R. Hetico RN MHA, on July 22, 2014 at 12:12 PM said:

   CMS Fraud Prevention System Identified Savings from (First/Second) Year (millions)

   1. Amount denied by pre payment edits 11.5/16.8
   2. Billed amount denied by auto-denial edits 4.7/1.6
   3. Payment suspensions 1.6/2.3
   4. Amount of overpayments referred for recovery 4.4/35.6
   5. Value of law enforcement referrals 68.2/73.2
   6. Cost avoidance due to changes in behaviour 11.1/NA
   7. Cost avoidance from revoking provider billing privileges 13.9/81.2
   8. Total 115.4/210.7

   Source: Centers for Medicare & Medicaid Services

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