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Panels scrutinize anti-fraud efforts


By Jessica Zigmond
Posted: March 2, 2011 - 6:15 pm ET
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Two House oversight committees on Wednesday examined public and private efforts to combat healthcare fraud as the Government Accountability Office reported that Medicare continues to be a “high-risk,” fiscally unsustainable government program.

Chairing the House Energy and Commerce Subcommittee on Oversight and Investigations, Rep. Cliff Stearns (R-Fla.) cited news reports that Medicare fraud is surpassing the drug trade as Florida's most profitable and efficient criminal enterprise, and he expressed frustration that only estimates—not exact numbers—are available to indicate how much is lost each year to Medicare fraud.

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“We're glad to implement any anti-fraud measures,” Stearns told the first panel of witnesses, which included John Spiegel, the director of Medicare program integrity at the CMS; Gerald Roy, deputy inspector general for investigations in HHS' office of the inspector general; Omar Perez, assistant special agent at the inspector general's office; and Kathleen King, director of the healthcare division at the GAO. “My concern is before we expand Medicare and Medicaid, we still don't know how much we've lost to fraud,” he continued. “It seems to me, if you don't have a handle on what the amount is, it's going to be difficult to penetrate it down.”

In her testimony, King said the GAO continues to designate Medicare as high-risk because its “complexity and susceptibility to improper payments, combined with its size, have led to serious management changes.” She reported that the CMS estimates that there was about $48 billion in improper payments for Medicare fee-for-service and Medicare Advantage for fiscal 2010. And while King's written testimony said the CMS has implemented some of the GAO's recommendations, she cited some areas that still require improvement, such as ensuring the implementation of an effective physician profiling system; improving management of payments for services, such as imaging; establishing policies to improve contract oversight; improving target review of claims for services with high rates of improper billing; and monitoring nursing homes that have serious care problems.

Stearns' concern about the estimate for Medicare fraud was also a topic of interest at an afternoon hearing of the House Ways and Means' Oversight Committee. Panel witness Lewis Morris, the chief counsel to the inspector general, said he estimates that healthcare fraud—in the public and private sectors combined—ranges from $60 billion to $100 billion. Morris also cited a figure that the inspector general's office's Roy mentioned in his testimony earlier in the day: For every $1 spent on the healthcare fraud and abuse control program, an average of $6.80 has been returned to the government.

Karen Ignagni, president and CEO of America's Health Insurance Plans, and Louis Saccoccio, executive director at the National Health Care Anti-Fraud Association, stressed the need for greater public-private partnerships in the afternoon panel.

“I think as CMS goes forward and develops their data analytics, the extent to which they can share that information with private insurers is helpful,” Saccoccio said. “As they begin to find trends and schemes, share that with the private side,” he added.

Ignagni highlighted four additional measures to prevent and detect fraud: recognize the role of fraud prevention and credentialing activities in quality improvement; enhance the information available to the private sector through increased data-sharing with the public sector; include private sector, government program components in federal cases; and provide stronger protections for private health plans that supply information on suspected fraud not just to the HHS secretary or attorney general, but to any other public or private entity.


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