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?
The Centers for Medicare & Medicaid Services has finalized rules that specify when the 60-day clock begins ticking for providers to return overpayments, and shaves four years off of the overpayment lookback period, according to FierceHealthFinance.
Cees Klumpler, chief risk officer for the Global Fund to Fight AIDS, Tuberculosis and Malaria, is responsible for $4 billion in annual funding that is distributed to 130 different countries. Following years of fraud and abuse that plagued the organization, Klumper has developed a unique 2-for-1 approach to recovering fraudulent payments. It's a methodology that the healthcare industry could benefit from.
The Centers for Medicare & Medicaid Services knew as far back as 2008 that certain Medicare Advantage plans were pocketing billions in overpayments, but officials still held back on auditing the plans and recouping payments tied to inflated risk scores, according to government records obtained by the Center for Public Integrity.
The Office of Inspector General is recovering less money from fraud investigations, but the agency is clearly shifting its focus toward civil actions, according to information included in the OIG's Semiannual Report to Congress.
A new federal directive will decrease the amount of hospital claims that Recovery Audit Contractors can review, effectively handcuffing the program's ability to root out improper payments.
More than 12,000 overpayment referrals are sitting untouched in the Nebraska Department of Health and Human Services' "overpayments mailbox," according to a state audit released last week.
A report released by the OIG Tuesday indicates that the Centers for Medicare & Medicaid's (CMS) Fraud Reporting System (FPS) resulted in more than $133 million in adjusted actual and projected savings within the Medicare program in 2014, translating to a $2.84 return on investment for every dollar spent on the program.
Just before the government announced nearly $28 billion in fraud recoveries since 1997, The Centers for Public Integrity released a report indicating the feds have known about problems with Medicare Advantage risk scores since 2009. The report questions whether those recovery dollars could be a whole lot higher if the investigators were willing to target a payment system that appears to be flawed.
When it comes to Mediciad recoveries, states with the largest numbers usually draw the most attention. But states such as Louisiana, which hone in on efficiency, may offer a better outlook into the true measure of fraud prevention.