Doctor Payment Data Will Enhance Fraud Investigations

The release of Medicare payment data has already identified numeorus doctors who continue to recieve payments from Medicare even though they have been previoulsy discplined and are therefore ineligible to participate in the Medicare program.  Many are questioning why such discoveries have been made so easily by media sources with access to little data while the federal government spends billions these entities to find individuals who are defrauding the Medicare program.  The answer maybe as simple as that there is so much fraud and abuse going on, why does it matter how fradulent individuals are caught just as long as they are.  The main point is that the release of payment data will make it even easier for federal and state fraud investigators to identify and further investigate individuals with unusual billing practices or who should not even be receiving any federal reimbursement at all.

High paid physicians. Eight physicians were recently identified by Businessweek who billed more than $7 million during 2012 to Medicare while their medical licenses were suspended,  expired, or revoked. In some instances, the magazine reported that doctors who had their license suspeneded or revoked in one state while they had a license in another state used the other state’s license to qualify for Medicare payments.  The Businessweek article noted that many had their licenses revoked or suspended for gross malpractice, battery or violating prescription drug laws.

The New York times reported that in 2012 about two percent of doctors received approximately $15 billion from Medicare or roughly one-fourth of the $77 billion paid to doctors that year. The same article went on to identify 100 doctors who recieved a total of $610 million in 2012.  This article did not claim that any Medicare payments were improper, and stated that some of these amounts included very expensive drugs.  The New York Times article did point out that fraud invesitgators across the country now have a treasure trove of data available to examine and help identify physicians and others who are billing in execess of other professionals or who may not be licensed at all.  The New York Times provided a look-up tool so you can see how much any particular doctor has received from Medicare.

Program integrity. The level of fraud and abuse against the Medicare program is unknown, but is thought to be quite substantial. One estimate by former CMS Administrator Donald Berwick is that the total amount of fraud against Medicare and Medicaid is between $30 billion and $98 billion a year.   Because this number is difficult to determine, the Government Accountability Office (GAO) continues to list Medicare as a program that is at high risk for fraud and abuse;  a description that the GAO has attributed to Medicare since 1990.

In 2013, the federal government spent $1.5 billion fighting health care fraud and abuse while recovering  $4.3 billion  from health care fraud settlments and court judgements, according to the Health Care Fraud and Abuse Control Program’s Annual Report for Fiscal Year 2013.  Increased efforts to reduce fraud and abuse was a part of the Affordable Care Act (ACA) (P.L. 111-148). Since 2011, 17,000 providers have been prohibited from billing Medicare as a result of an ACA requirement that all 1.5 million providers and suppliers be rescreened, according to the testimony of Dr. Shantanu Agrawal, Deputy Administrator and Director of CMS’ Center for Program Integrity delivered to  before the Senate’s Select Committee on Agining in March 2014.  The rescreening found providers who were ineligible to participate in Medicare because they had felony convicitions, did not have the appropriate medical license, or had the wrong address on file.  In addition 260,000 suppliers and providers had their participation in Medicare revoked for not responding at all to the request for the rescreening.

The release of the amount paid to physicians by Medicare should increase the success of  fraud investigators who no doubt will follow the lead of journalist in identifying irregular billing patterns and people who do not meet the requirements to bill Medicare at all.