The Centers for Medicare & Medicaid Services took a beating from members of a Senate subcommittee Tuesday for incomplete implementation of fraud prevention programs and for missing key deadlines.
A cornerstone of the nearly two-hour hearing included the release of a particularly negative report from the U.S. Government Accountability Office, which said CMS had allowed only 42 of 639 analysts to undergo training to use a database that was tailored to identify fraud and questionable claims worth $21 billion over 10 years.
Additionally, CMS has not incorporated any data from Medicaid claims, a major potential source of healthcare fraud and abuse, into the system, GAO charges.
The system, as it is, "entices predators...to gorge on the cash cow, which these programs represent, and it's the government's chronic mismanagement of Medicare and Medicaid fraud prevention that's landed both programs on the GAO's high risk list for many years," said Sen. Scott Brown, (R-MA).
Brown is ranking member of U.S. Senate Subcommittee on Federal Finance Management, of the Committee on Homeland Security and Government Affairs, which held the hearing, "Harnessing Technology and Innovation to Cut Waste and Curb Fraud in Federal Health Programs."
"The government's history of overseeing the performance of these programs in the last few decades does not indicate a history of success," Brown added. "In light of the burgeoning wave of healthcare spending and history of lax oversight, we need to do more and we need to do it quickly."
Committee Chairman Sen. Tom Carper, (D-DE), asked CMS's director for the Center for Program Identity Peter Budetti, MD, "When will we have more people trained and when will state Medicaid offices have access to this information?"
Brown added, CMS was "supposed to have 639 (trained by the end of the fiscal year. Looks like we're a little short," he said, on personnel necessary "to use a system that cost $100 million."
"Are we getting a good value? Is it reaching its full potential? It doesn't seem to be but maybe I'm missing something," he added.
Budetti responded that the number of analysts scheduled for training was set a number of years ago, and implied that may not be the number that would still be trained to use the system. However, he clarified that another 55 analysts had been trained to date.
Budetti touted CMS's launch on July 1 of predictive analytics technology that screens claims before payment. The technology is similar to that used by credit card companies to analyze customers' spending trends and quickly detect irregularities, and to stop those claims from being paid until they are properly investigated.
Lewis Morris, chief counsel for the U.S. Office of Inspector General, who appeared as one of the hearing's witnesses, said, however, that there have been only 53 payment suspensions initiated at the OIG's request, representing about $8 million, since the passage of the Affordable Care Act last year.
Carper and Sen. Tom Coburn, (R-OK), last month introduced a bill they call the FAST Act: Medicare and Medicaid Fighting Fraud and Abuse to Save Taxpayers Dollars. It would increase criminal penalties for fraud, encourage seniors to report fraud and abuse through the Senior Medicare Patrol, and would improve fraud coordination between state and federal governments as well as require deployment of data analysis technology.
In his opening remarks during the hearing, Carper lamented recent findings that half of Medicare spending for power wheelchairs went for claims that either weren't medically valid or weren't properly documented, "and we have dead doctors writing prescriptions for controlled substances...It's far too easy for bad people to get provider IDs."
He also said in a statement that Medicare's estimate of $47.5 billion that was paid out for improper claims in fiscal 2010 "does not even include an estimate for the Medicare prescription drug program, which I'm told could add more than $5 billion to that total. For Medicaid, the improper payments figure is $22.5 billion."
Also testifying during the hearing was Louis Saccoccio, executive director of the National Health Care Anti-Fraud Association, who estimated healthcare fraud estimates ranging from $75 billion to $250 billion a year.
"These financial losses are compounded by numerous instances of patient harm – unfortunate and insidious side effects of healthcare fraud."
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