“Where there’s smoke, there’s usually fire.” Law enforcement applies this age-old adage when it focuses investigative efforts on suspicious activity. However, according to a recently released HHS-OIG report, the Centers for Medicare & Medicaid Services (CMS) and its contractors have not been zeroed in on health care providers who have repeatedly submitted incorrect bills to the Medicare program.

Last year, CMS compiled the error-rate data from fiscal years 2005 through 2008 from two specific programs, the Hospital Payment Monitoring Program (HPMP) and the Comprehensive Error Rate Testing (CERT) program. The results spotlighted a number of “error-prone” health care providers who regularly submitted incorrect claims to the Medicare program. In fact, CMS specifically identified a total of 740 providers who were especially “error-prone,” defined as having at least one error per year during the examination period.

As revealed in the report, OIG discovered that CMS never used this data to further examine the billing habits of these error-prone providers. Moreover, Recovery Audit Contractors and Program Safeguard Contractors also did not focus on error-prone providers, as CMS did not share the HPMP and CERT error-rate data.

In its final recommendation, OIG said that CMS should use error-rate data to focus on error-prone providers, share the data with all its contractors, and require error-prone providers to develop and implement corrective action plans.

In short, when CMS detects smoke, it should look to see if there’s a fire.

For more information about qui tam law and Medicare fraud, contact Nolan and Auerbach, P.A.