HHS Officials Explain $47.9B in Improper Medicare Payments
Daly said her office has identified five strategies to help reduce fraud, waste, and abuse, and halt improper Medicare payments. Not all have yet been acted upon:
1.) Strengthen provider enrollment standards and procedures. Strong standards and procedures can help reduce the risk of enrolling sham providers. CMS has implemented provisions of the Patient Protection and Affordable Care Act that screen providers by levels of risk and provide a stringent review of high-risk providers, but has yet to implement certain GAO recommendations in this area.
2.) Improve prepayment reviews. Prepayment reviews of claims help ensure that Medicare pays correctly the first time. As of July 1, 2011, CMS has begun applying predictive modeling analysis to claims and plans to expand Medicare prepayment controls. CMS has not implemented GAO's recommendation to improve prepayment reviews.
3.) Focus post-payment reviews on vulnerable areas. Post-payment reviews are critical to identifying payment errors and recouping overpayments. In March 2009, CMS began instituting a national recovery audit contractor program to help the agency supplement its post-payment reviews. CMS has also developed information technology to help it better identify claims paid in error, but GAO recently reported that the systems are not being used to the extent originally planned and made several recommendations to address the issues.
4.) Improve oversight of contractors. CMS has taken action to improve oversight of prescription drug plan sponsors' fraud and abuse programs, which addresses GAO's recommendation, but is still developing specific performance statistics.
5.) Develop process to address identified vulnerabilities. CMS has not developed a robust corrective action process for vulnerabilities identified by Medicare RACs as GAO recommended.
John Commins is a senior editor with HealthLeaders Media.
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