Patients First: A 21st Century Promise to Ensure Quality and Affordable Health Coverage : Joint Hearing Before the Subcommittee on Health and the Subcommittee on Oversight and Investigations of the Committee on Energy and Commerce, House of Representatives, One Hundred Seventh Congress, First Session, June 28, 2001, Volume 4

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Page 15 - ... altering documents and falsifying statements that specific work was performed In some cases, contractors prepared bogus documents to falsely demonstrate superior performance for which Medicare rewarded them with bonuses and additional contracts. In other examples, contractors adjusted their claims processing so that system edits designed to prevent inappropriate payments were turned off, resulting in misspent Medicare Trust Fund dollars. We have also encountered problems associated with...
Page 47 - Shield Plans serve as Part A Fiscal Intermediaries (FIs) and/ or Part B carriers and collectively process most Medicare claims. Blue Cross and Blue Shield Medicare contractors are proud of their role as Medicare administrators. While workloads have soared, operating costs — on a unit cost basis — have declined about two-thirds from 1975 to 2001. In fact, contractors' administrative costs represent less than 1 percent of total Medicare benefits. Few government expenditures produce the documented,...
Page 48 - Inadequate budgets for program management also impact Medicare's fight against fraud and abuse. While many think of program management activities as simply paying claims, these activities are Medicare's first line of defense against fraud and abuse and are critically linked to MIP activities. As an example, many of the front-end computer edits (eg, preventing duplicate payments and detecting suspicious claims) are funded through program management Inadequate funding impacts different functions at...
Page 47 - During the early to mid-1990s, reductions in funding concurrent with increases in workload seriously eroded contractors' ability to fight fraud and abuse. Between 1989 and 2000, the number of Medicare claims climbed almost 70 percent to over 800 million, while payment review resources grew less than 11 percent. As a result...
Page 46 - Medicare and respond to approximately 40 million inquiries annually. 3. Handling Hearings and Appeals: Beneficiaries and providers are entitled by law to appeal the initial payment determination made by carriers and FIs. These contractors handle over 7.4 million annual hearings and appeals. 4. Special Initiatives to Fight Medicare Fraud, Waste, and Abuse: All contractors have separate fraud and abuse departments dedicated to assuring that Medicare payments are made properly. According to the Department...
Page 46 - FY 2001, it is estimated that contractors will process over 900 million claims, more than 3.5 million every working day. 2. Providing Beneficiary and Provider Customer Services: Contractors are the main points of routine contact with Medicare for both beneficiaries and providers. Contractors educate beneficiaries and providers about Medicare and respond to approximately 40 million inquiries annually.
Page 18 - For purposes of this part, the term "carrier" means— (1) with respect to providers of services and other persons, a voluntary association, corporation, partnership, or other nongovernmental organization which is lawfully engaged in providing, paying for, or reimbursing the cost of, health services under group insurance policies or contracts, medical or hospital service agreements, membership or subscription contracts, or similar group arrangements, in consideration of premiums or other periodic...
Page 47 - Thanks to this new funding mechanism, Medicare contractors have been able to improve their efforts to reduce the amount of fraud, waste, and abuse in the Medicare program. Contractors' enhanced anti-fraud and abuse efforts due to MIP funding contributed to the significant decline in improper claims and documentation submission by providers. The OIG audit of FY 2000 claims estimated that improper Medicare payments had dropped to $11.9 billion, or about 6.8 percent of the $173.6 billion in Medicare...
Page 81 - Intermediary shall reimburse the United States for the amount of any valid judgment or award paid by the United States in the discharge of the Secretary's obligations under this Article if the liability underlying the judgment or award was the direct consequence of conduct on the part of the...
Page 46 - Centers for Medicare and Medicaid Services (CMS), formerly known as the Health Care Financing Administration, which, during fiscal year 2000, was responsible for processing more than $200 billion in Medicare expenditures.

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