HHS Estimates $48 Billion of Improper Payments Were Paid to Healthcare Providers in 2010

According to an article by the RAC Monitor, the U.S Department of Health and Human Services (HHS) recently reported that an estimated $48 billion was improperly paid to providers in 2010. However, due to HHS’s currently undeveloped comprehensive projection for the Medicare prescription drug benefit, the U.S. Government Accountability Office (GAO) has determined the estimated $48 billion in improper payments is incomplete and possibly underestimated. The GAO provided testimony before the U.S. House of Representatives Subcommittee on Government Organization, Efficiency and Financial Management, whereby the GAO produced a number of recommendations in an effort to aid the Centers for Medicare & Medicaid Services (CMS) in fortifying its ability to prevent or detect and recoup improper payments to healthcare providers.

Among other reasons, the GAO alluded to a number of key causes for the improper payments, such as coding and payment calculation errors, inadequate documentation and services deemed not to be medically necessary. In 2010, CMS initiated the Center for Program Integrity to handle all Medicare integrity issues. The GAO recently made recommendations to CMS to help strengthen its ability to minimize Medicare fraud, waste and abuse. According to the article, the GAO’s recommendations are as follows:

1. Strengthen provider enrollment standards and procedures.

2. Improve prepayment reviews.

3. Focus post-payment reviews on vulnerable areas.

4. Improve oversight of contractors.

5. Create a robust process to address identified vulnerabilities.

With the expected improvements to CMS’s strategies to recoup improper payments, providers need to make sure that they are in full compliance to be protected against a potential audit. If you need help defending against Medicare/Medicaid audits or investigations, or assistance with implementation of a proactive corporate compliance program, please contact a Wachler & Associates attorney at 248-544-0888.

GOA Report: http://www.gao.gov/new.items/d11409t.pdf

RAC Monitor Article: http://www.racmonitor.com/news/43-special-bulletin/630-gao-reports-billions-in-improper-medicare-payments.html