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Survival in New Era of Enforcement a Tall Order for Hospitals

Andrea Kraynak, for HealthLeaders Media, December 3, 2009

The struggling economy has left many hospitals with thin wallets, and government auditors are gunning for what's left.

There are big dollars at stake. The Government Accountability Office recently released a report that estimated the following overpayment amounts in 2008:

  • Medicaid, $18 billion. Medicaid hasn't been policed as strictly as Medicare. As a result, overpayments and sometimes even fraud have flourished, according to Michael Taylor, MD, senior medical director of government and regulatory affairs at Executive Health Resources, who spoke at the recent HCPro "Medicare Compliance Forum" held in Atlanta. "But those days are over, and CMS will be examining it as closely as the other programs," he said.

  • Medicare fee for service, more than $10.4 billion.  

  • Medicare Advantage, $6.8 billion. The estimated Medicare Advantage overpayments have led some members of Congress to propose extending the RAC program to the Medicare Advantage program. "Imagine what that would look like," said Taylor. "Once the Medicare Advantage payers start to see the RAC program expanded, they'll then start to learn from the RACs. And they start to use the same techniques themselves.

"We've all heard the saying, ‘A billion here a billion there, soon it adds up to real money.' That's what we're seeing here," Taylor explains.

Hence the arrival of the many auditors—from RACs to ZPICs—looking for Medicare and Medicaid overpayments or fraud. They're looking for billions.

Thus, we enter a new era of smart, aggressive enforcement.

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