Healthcare News & Insights

Why you’ll have to try extra hard to stay on CMS’ good side

Hospital leaders may soon see a lot more federal scrutiny over their Medicare services and billing. 

186260545It looks like issues with Medicare payments aren’t only raising public ire, but will likely result in a lot more fraud investigations and data collection for hospitals and other healthcare facilities.

A recent Medicare fraud sweep led to 90 arrests in six different cities, according to Modern Healthcare.

Most of the arrests involved false billing claims, which cost the program $260 million in the past year. Twenty-seven of those arrests involved healthcare professionals, 16 of whom were doctors.

The sweeps show the government’s continued struggle and increased efforts to crack down on Medicare fraud. The Medicare Fraud Strike Force have charged nearly 2,000 people for billing false claims to Medicare for more than $6 billion since 2007.

To help their efforts, Medicare and the Department of Health and Human Services (HHS) and the Department of Justice often try to identify shady Medicare billing patterns and have stalled provider enrollment in high-risk areas.

You might expect that all this boosted effort means some real progress is being made to curb fraud.

Progressing by inches

Sadly, Medicare fraud and improper payments continue to be huge issues.

A recent article from FierceHealthPayer notes that improper fee-for service payments made up 10% of Medicare expenditures, or about $50 million, just in 2013. And what’s got people and policy-makers even angrier is that this percentage has actually risen since last year — meaning fraud and improper payments have gotten worse, despite everyone’s good intentions.

Gloria Jarmont, HHS’ deputy inspector general, highlighted three areas that she feels need closer scrutiny from the Centers for Medicare & Medicaid Services (CMS):

  1. Payments for ineligible persons such as unlawfully present, entitlement-terminated, jailed and deceased beneficiaries.
  2. Payments for prescription drugs from unqualified or questionable prescribers, and
  3. Payments to hospitals. Jarmont believes CMS can reduce costs by taking better advantage of recovery audit contractors data to improve Medicare Parts C and D, revising payment policies for certain hospital services and conducting prepayment and postpayment claims reviews to identify improper payments.

Cracking down on wasteful services

Jarmont’s recommendations could easily lead to increased hospital scrutiny, especially since Medicare is hoping to crack down on unnecessary and unhelpful patient services, according to a different Modern Healthcare article.

A recent study from JAMA Internal Medicine found that 42% of Medicare patients received care that didn’t help them very much, but which cost the program about $8.5 million.

The areas of services which were often overused included: cancer screenings, diagnostic and preventive testing, preoperative testing, imaging, and cardiovascular testing and procedure. All the categories of “unnecessary care” varied based on the region being tested.

The potential for savings may mean more pressure for improved care from federal agencies and quality campaigns like  “Choosing Wisely. It may be worth taking a look at how your region fared in terms of billing unnecessary or wasteful procedures to see if your facility might come under fire.


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