In 2012, Olympus warned European hospitals that one of its medical scopes was harboring dangerous bacteria. More than two years later, U.S. hospitals reported infectious outbreaks linked to the same scope that ultimate infected more than 250 people between 2012 and 2015. The patient safety debacle left many wondering how this could happen. A massive kickback scheme that predated the outbreak offers some belated clues, revealing an eroded corporate culture that valued profits over compliance, regardless of the repercussions.
With a growing budget, higher enrollment numbers, and a rising improper payment rate, Medicaid sustainability depends on better fraud prevention and more accountability from states, according to a report from the American Action Forum.
The new bounty hunter isn't the gun-toting folklore of the Wild West. Instead, like John Minnino, they rely on algorithms and claims data first, and whistleblowers second, to hunt down potential fraudsters. It's a more targeted approach that could open the door for a boon in the business of fraud fighting.
The hospice industry has become an easy target for criminals looking to stretch the definition of "terminally ill," thanks to lackluster federal oversight and a low bar for coverage, according to the Pittsburgh Post-Gazette.
A recently unsealed lawsuit suit claims Humana encouraged physicians to elevate patient conditions in an effort to inflate Medicare Advantage risk scores, and then turned a blind eye when one physician voiced concerns, according to a report jointly published by the Center for Public Integrity and NPR.
One of the nation's largest oncology care providers has agreed to pay $35 million to settle claims it billed for unnecessary radiation testing, according to the Wall Street Journal.
A proposed rule released by the Centers for Medicare and Medicaid Services would expand the power of government officials to deny or revoke billing privileges for providers that pose a risk to federal healthcare programs.
Last week's report from the Government Accountability Office made waves after the agency characterized enrollment fraud detection within the federal Affordable Care Act marketplace as "passive," a word that many latched on to as way of denouncing the president's landmark healthcare legislation. Although the GAO pointed out some valid criticisms of ACA fraud detection, this submissive approach to fraud prevention seems to reflect a widespread systemic issue among government-run programs dating back to the inception of Medicare and Medicaid.
Data transparency, enhanced provider screening software and additional site visits will serve as key components of the federal government's upgraded approach to fraud detection and prevention, outlined in two new programs announced by the Centers for Medicare & Medicaid Services last week.
Medicaid Fraud Control Units were notably inefficient in 2015, recovering just $744 million of an estimated $53.6 billion in improper payments. These numbers are particularly concerning given the increase in Medicaid enrollment, the projected spending within the program over the next six years and the fact that improper payment rates continue to push skyward. Is this a one-year anomaly, or is an unmanageable Medicaid budget outpacing our existing tools for controlling fraud?
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