Medicare Fraud

Every year, we lose billions of dollars to fraud in federal and state health care programs. Every dollar we lose to fraud and abuse is a dollar that is not available to provide home care to seniors, to treat HIV and AIDS, to immunize children, and to discover new treatments for cancer and other diseases. Some fraud schemes even pose a direct threat to the health and safety of patients. Many instances of health care fraud sug­gest that existing control systems do not work the way we imagine they should. Often the manner in which schemes are revealed suggests detection is more luck than system. Whistleblower lawsuits have exposed billing by health care providers for services not rendered, billing for products not delivered, misrepresenting services, unbundling services, billing for medically unnecessary services, duplicate billing, increasing units of service which are subject to a payment rate, falsifying cost reports resulting in increased payment to the health care provider, kickbacks, and on and on. Healthcare fraud is still going strong and this blog is intended to keep readers up to date with all healthcare fraud related news and to provide commentary when warranted. This blog also contains an array of laws and regulations concerning healthcare fraud set out in an easy to read format.

CMS Steps Up Efforts to Ferret Out Fraud -Southern Florida is mentioned

by Nolan and Auerbach on October 24, 2006

CMS recently announced multiple accomplishments and projects, all designed to reduce fraud and abuse: the Los Angeles office of CMS revoked the billing numbers of 117 providers who had presented false claims or suspicious business operations, saving $200 million, editing the system to stop payment on claims using billing numbers from deceased providers saved another $4 million, and targeted efforts against independent diagnostic testing facilities resulted in revocation of the billing privileges of 83 IDTFs and denied $445 million in claims for “beneficiary sharing.”

CMS also announced that it had expanded its satellite offices in Miami and Los Angeles, “providing additional on-the-ground efforts to identify and report fraud, waste and abuse in Medicare.” In addition, activity in the Miami office has included a cooperative federal/state task force on abuses by independent diagnostic facilities investigating complaints and using site visits, record reviews, administrative actions and data analysis. CMS announced that it and the Florida agencies have referred 400 criminal investigations to law enforcement authorities, revoked the licenses and billing privileges of clinics and practitioners, and added edits to the claims system to “auto deny” claims for medically unbelievable services and flag high-volume claims for particular services. CMS further announced that the U.S. Department of Justice has begun 63 criminal cases and 38 civil cases involving Medicare fraud since October 2005.

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