In fiscal 2015, the federal government recovered about $2.4 billion in healthcare fraud and it is working to improve proactive data analyses to prevent improper payments, experts said at a congressional hearing Wednesday.
Officials from a U.S. attorney's office and HHS' Office of Inspector General as well as a private contractor testified that incidents of prescription drug, medical device and home-based services fraud are growing and are of particular concern for government and law enforcement agencies.
Rep. Peter Roskam (R-Ill.) said the hearing was part of the House Ways and Means Subcommittee on Oversight's two-year look into healthcare investigations and Medicare fraud. Illegal schemes have worsened the nation's opioid epidemic and in some cases resulted in direct patient harm in addition to financial losses for taxpayers, he said.
Roskam said the budget process is part of the problem, because the Congressional Budget Office does not count preventing unlawful payment as savings and does not take into account the costs of investigating and prosecuting cases.
He said the subcommittee was unimpressed with efforts described by the CMS at an earlier hearing of “making the payment and only checking after the fact to see if it was proper.”
Health Integrity Senior Vice President Scott Ward said his company, which is contracted by the CMS, establishes priorities with a matrix that considers factors such as the amount of money involved, involvement of quality of care and type and geographic area of an allegation.
Ward said he also works to determine program vulnerabilities, such as a gap in Oklahoma's Medicare policy that allowed up to 15 agencies to provide free diabetic test strips to one patient.