A drop in the bucket…

Every year, the Centers for Medicare and Medicaid Services (CMS) conducts a recovery audit. In a recent report, Medicare collected over $797 million in Medicare overpayments in 2011. Where do these overpayments come from? Inpatient: $677m Durable Medical Equipment & Other: $35m Physician: $33m Outpatient: $17m Skilled Nursing Facilities: $0.2m Recovery Audit Contractors returned $488…

How much money does Medicare waste?

The answer depends on who you ask. According to the GAO, Medicare spent $48 billion in “improper payments,” which include fraud but also waste, eligibility errors, miscoded claims and insufficient documentation. GAO determined that Medicare’s traditional fee-for-service plan had a 10.5 percent error rate. Attorney General Eric Holder, suggest there may be $60 billion in…

The Bernie Madoff of Medicare?

Physicians earn high salaries.  The Bureau of Labor Statistics notes that the median primary care physicians made $186,044, and specialists typically earn  $339,738.   Some physicians earn much more than that, but not always through legitimate means. Consider the case of Dr. Jacques Roy: Federal law enforcement officials announced charges in the largest healthcare fraud scam…

Fraudulent Cancer Research: An Exception or the Tip of the Iceberg

Yesterday, 60 Minutes reported on Dr. Anil Potti, researcher at Duke University.  Dr. Potti supposedly offered cancer patients improved cancer treatments.  These recommendations, however, were based on falsified data. “Five years ago, Duke University announced it had found the holy grail of cancer research. They’d discovered how to match a patient’s tumor to the best chemotherapy…

Is Medicare moving towards rationing your medical equipment?

Currently, Medicare fee-for-service (FFS) beneficiaries receive significantly more choice than standard commercial plans.  They can choose any provider they wish (who accepts Medicare).  There are no cost-sharing differences between in-network and out-of-network doctors (because there is no ‘in-network’ for Medicare).  Although certain Part D prescription drug plans require prior authorization for specific drugs, few services…

MedPAC’s Home Health Recommendations

In their latest 2011, MedPAC made four recommendations to alter payment policy in the home health setting.  These include the following: The Secretary, with the Office of Inspector General, should conduct medical review activities in counties that have aberrant home health utilization.  The Secretary should implement the new authorities to suspend payment and the enrollment…

The Medicaid Integrity Program

One of President Obama’s biggest initiatives as part of health reform was to reduce fraud, waste and abuse in Medicare and Medicaid.  Today, I will discuss how the Medicaid program fights fraud at the federal level. Because Medicaid is state-run, the States have typically been the ones responsible for ensuring efficient Medicaid operations. However, the…

Book Review: Undercover

In 2006, Columbia/HCA was forced to return $1.7 billion to the federal government for defrauding Medicare. How was the federal government able to amass such strong evidence against HCA in order to win such a large settlement? The answer to the question is revealed in a book called Undercover by John W. Schilling. The book…