Medicare: Improvements Needed to Address Improper Payments for Medical Equipment and Supplies
DIANE Publishing, 2007 - 29 pages
The Centers for Medicare & Medicaid Services (CMS) -- the agency that administers Medicare -- estimated that the program made about $700 million in improper payments for durable medical equipment, prosthetics, orthotics, & supplies (DMEPOS) from April 1, 2005, through March 31, 2006. To protect Medicare from improper DMEPOS payments, CMS relies on 3 Program Safeguard Contractors (PSC), & 4 contractors that process Medicare claims, to conduct critical program integrity activities. This report examines CMS¿s & CMS¿ contractors¿ activities to prevent & minimize improper payments for DMEPOS, & describe CMS¿s oversight of PSC program integrity activities. Includes GAO recommendations. Charts & tables.
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Appendix Aronovitz assess atypical billing patterns automated prepayment controls beneﬁt integrity activities Centers for Medicare CIGNA CMS contractors conduct program integrity deny claims DME MAC contract DMEPOS claims data DMEPOS Claims Processing DMEPOS regions Durable Medical Equipment Equipment Regional Carrier ﬁrst quarter HHS OIG identiﬁed identify claims implementing improper claims improper DMEPOS payments increases in billing insulin investigating and prosecuting Joint Operating Agreements law enforcement ofﬁcials Medicaid Services Medical Equipment Regional medical review edits medical review strategies medically improbable claims Medicare & Medicaid Medicare DMEPOS claims Miami minimize improper payments ofﬁcials we interviewed orthotics payments for DMEPOS prevent and minimize program integrity activities program integrity efforts Program Safeguard Contractors prosecuting Medicare fraud prosthetics PSC performance PSC’s quarter of 2003 referrals Region D Regional Carrier DMERC review and beneﬁt SADMERC Safeguard Contractors PSC Scope and Methodology speciﬁc suspected fraud test strips unexplained increases Washington wheelchairs
Page 20 - We will also make copies available to others on request. In addition, the report will be available at no charge on GAO's Web site at http://www.gao.gov. If you or your staffs have any questions about this report, please contact me at (202) 512-7101 or BascettaC@gao.gov.
Page 4 - Department of Health and Human Services (HHS) Office of Inspector General (OIG), which oversees MFCUs at the federal level.
Page 6 - Medicare is the federal program that helps pay for a variety of health care services and items on behalf of almost 42 million elderly and certain disabled beneficiaries.
Page 1 - Both result in unnecessary costs to the insurer; but fraud generally involves a willful act, whereas abuse typically involves actions that are inconsistent with acceptable business and medical practices. As a practical matter, whether and how a wrongful act is addressed can depend on the size of the financial loss incurred and the quality of the evidence establishing intent. For example, small claims are generally not pursued as fraud because of the cost involved in investigation and prosecution....
Page 4 - I contains a more detailed discussion of our scope and methodology.) We performed our work between December 2000 and December 2001 in accordance with generally accepted government auditing standards. 2 Hereinafter, the term "states" will refer collectively to the 50 states plus the District of Columbia and Puerto Rico.
Page 29 - August 17, 2005. Health Care Fraud and Abuse Control Program: Results of Review of Annual Reports for Fiscal Years 2002 and 2003. GAO-05-134. Washington, DC: April 29, 2005. High-Risk Series: An Update. GAO-05-207. Washington, BC: January 2005.
Page 26 - Thank you for the opportunity to review and comment on the subject draft report.