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Suspicion of Medicare Fraud Triggers Most Reimbursement Suspensions

Cheryl Clark, for HealthLeaders Media, November 3, 2010

It is unclear from the OIG report how many of these providers were eventually found to have committed fraud. However, the billing patterns included "aberrantly high amounts of services provided within a short timeframe and spikes in billing as a result of multiple claims submitted for the same beneficiary."

Additionally, "the contractors' analyses also showed that some of the suspended providers billed Medicare using stolen identities" and used ID numbers "that were known to have been compromised."

Other providers "aberrantly billed for medical equipment, submitting claims that listed neurosurgeons, pediatricians, and pathologists as the ordering physicians. Those specialties do not typically order such equipment."

The OIG also concluded that CMS current policy "provides inconsistent guidance on payment suspensions, particularly in specifying the types of information that its contractors should submit with a request for a suspension, as well as in describing to contractors and law enforcement the circumstances in which an extension is permitted."

For example, CMS' Program Integrity Manual requires contractors requesting suspension for providers to submit "other supportive information but the manual does not specify what type of information is needed.

Also, it's unclear from CMS documents whether the authority to approve suspensions rests with CMS' central office or with regional offices, and CMS lacks standardized model suspension notices that include all required information, to avoid potential delays in the suspension process.

The OIG's conclusions are significant in light of the fact that the Affordable Care Act requires new standards by which fraud suspicion may result in payment suspension or delay, and requires CMS to review with the OIG "in determining whether a credible allegation of fraud exists."

Proposed rules were issued on Sept. 23 and published in the Federal Register. (75 Fed. Reg. 58204, 58239)

The OIG report also gave details on which types of payments were suspended. While payment suspensions in both years were concentrated in Part B, there was some shifting between 2007 and 2008.

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