By Carol Miller RN MBA
The Cost of Health Fraud
There is no question that real fraud, waste and abuse exists in healthcare today. The Office of Inspector General of the Department of Health and Human Services (HHS) saved American taxpayers a record $21 billion a dozen years ago, according to Inspector General Janet Rehnquist. Savings were achieved through an intensive and continuing crackdown on waste, fraud and abuse in Medicare and over 300 other HHS programs for which the Office of Inspector General (OIG) has oversight responsibility.
More recently, according to the Centers for Medicare and Medicaid Services [CMS] and under the tenure of Eric Himpton Holder, Jr., 82nd Attorney General of the United States and more recently Loretta Lynch, Recovery Asset Contractors [RACs] collected almost $1-B in improper payments during their beta testing period in 2009-10.
Of these payments; 96% were over-payments, 4% were under-payments; and 77% of providers failed to appeal, 7% appealed successfully and 15% appealed unsuccessfully.
And, by Fiscal Year 2016, recovery auditors collectively identified and corrected more than 1,532,249 claims for improper payments, which resulted in more than $3.75 billion dollars in improper payments being corrected. The total corrections identified include more than $3.65 billion in overpayments collected and $102.4 million in underpayments repaid to providers and suppliers.
After taking into consideration all fees, costs, and first level appeals, the Medicare FFS Recovery Audit Program returned over $3.0 billion to the Medicare Trust Funds.
These savings did not take into account program costs and administrative expenses incurred at the third and fourth levels of appeal (Office of Medicare Hearings and Appeals (OMHA) and Medicare Appeals Council within the Departmental Appeals Board (DAB), respectively), as these components do not receive Recovery Audit Program funding for those appeals.
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Filed under: Ethics, Risk Management | Tagged: Carol Miller RN MBA, health fraud, Medicare FFS Recovery Audit Program, Office of Medicare Hearings and Appeals, RACs, Recovery Asset Contractors, Recovery Audit Program |