As taxpayers, we can feel the financial impact when billions of dollars of our hard earned money is paid to entities that have inappropriately billed services to the Medicare Fee-for-Service program.  Americans frequently hear about the deficit, budget shortages and the tenuous future of Social Security.  Fraudulent billing just compounds this situation.

In an effort to increase awareness and provide valuable tools to combat fraud and abuse, CMS recently published a fact sheet ICN006827: “Medicare Fraud & Abuse, Prevention, Detection, and Reporting”.

CMS has been successful in fighting fraud:

 Medicare, Medicaid, and CHIP have experienced a record level of recoveries—$4.2 billion in fiscal year 2012—and a record return on investment— $7.90 for every dollar invested.  

Total recoveries over the past four years were $14.9 billion compared to $6.7 billion over the prior four years.

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In order to fight fraud and abuse, you need to recognize it.

Fraud is:

A provider or organization that bills for services not furnished, supplies not provided, or both.

Falsifying records to show delivery of such items not furnished.

Billing Medicare for appointments that the patient failed to keep.

The solicitation of referrals and/or exchanging any type of payment in order to obtain referrals for services or supplies covered by Medicare.

               

 

Abuse is:

Practices that result in unnecessary costs to the Medicare Program.

Delivering items or services to Medicare beneficiaries that are not medically necessary.

Providing treatments that do not follow established accepted medical standards of care.

Charging inflated rates for items or services.

Upcoding for services or unbundling services to increase payment rates.

Fraud and abuse are crimes and perpetrators are subject to fines, loss of license and imprisonment if convicted.

CMS utilizes the assistance of outside entities to prevent, detect, and investigate potential Medicare fraud and abuse:

Comprehensive Error Rate Testing (CERT) Contractors

 

Medicare Administrative Contractors (MACs) which pay claims and enroll providers and suppliers

               

Medicare Drug Integrity Contractors (MEDICs)

 

Recovery Audit Program Recovery Auditors

 

Zone Program Integrity Contractors (ZPICs)

Those responsible for pilfering the coffers of our country are hurting everyone and need to be brought to justice. Providers can contact the Office of the Inspector General (OIG) at 1-800-HHS-TIPS (1-800-447-8477) or their local Medicare Adminstrative Contractor (MAC) to report suspected fraud and abuse.   

Complaints registered with the OIG can always remain anonomous, but by providing your name it will facilitate their ability to conduct a more thorough research of the situation.