Congress Scolds CMS for Failing to Curb Medicaid, Medicare Fraud and Abuse
 

Question: 
Why is the CMS failing to tackle Medicare and Medicaid Fraud and Abuse?
 
Answer: HHS' Office of Inspector General released three (3) reports Tuesday timed to a House Energy and Commerce Committee's Subcommittee on Oversight and Investigations hearing on combating improper payments and ineligible providers. 

The OIG found that 37 states had not implemented fingerprint-based criminal background checks, and 11 were not performing site visits when enrolling providers in their Medicaid programs.
 
The OIG also found that the CMS does not have a comprehensive database for identifying providers that have been terminated for cause. This has resulted in a significant number of providers continuing to bill Medicaid in one state when they were terminated in another. According to the OIG, 12% of providers terminated for cause by a Medicaid agency in 2011 were still participating in another state's Medicaid program in January of 2012.

The OIG’s report also found that the Medicare enrollment data system called PECOS (“Provider Enrollment, Chain and Ownership System”) remains incomplete, inconsistent and inadequate. A recent review found that nearly all provider names from PECOS did not match the names filed with state Medicaid agencies. Also, many ownership names in PECOS did not match those collected directly from providers. Investigations by the Government Accountability Office found more than 26,000 providers with addresses not matching any on file with the CMS.

A representative from the CMS stated that many of the questionable payments result from mistakenly incomplete documentation from providers, and that the CMS relies on states for verifying Medicaid information. The CMS vowed to continue its work with the states to rectify this issue.

Medicare and Medicaid fraud and abuse remains a top priority as the numbers indicate much work remains to be done. In 2014, the government reported nearly $80 billion misspent on Medicare and Medicaid. 
 
Weekly Charting Tip:
When your chart states that the patient is improving, that is insufficient. The chart must state HOW your patient is improving- be specific if possible. This will help protect you against audits that find that the patient is not getting any benefit from your continued treatment. 
 
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