Monday, December 29, 2014

Why It’s So Hard to Fix Medicare Fraud

CMS Tries to Reduce Fraud, Abuse Without Restricting Care
John and David Mkhitarian found a soft spot in Medicare’s defenses against fraud: Inspectors aren’t required to visit medical providers deemed to present a lower risk of fraud and abuse.
So the cousins used exchange students to create some 70 bogus laboratories, clinics and physician practices, then enrolled the companies in the program with the stolen identities of doctors, prosecutors assert. Medicare paid out $3.3 million over about two years.
The Centers for Medicare & Medicaid Services 
headquarters' offices in Woodlawn, Md. Bloomberg News
Both Mkhitarians pleaded guilty to health-care fraud conspiracy. David was sentenced in September to seven months in prison, and John will be sentenced in February.
Their case illustrates a vulnerability in the nearly $600 billion taxpayer-funded program: Vetting of new providers often is inadequate. An inspection of the Mkhitarians’ companies might have stopped the scheme before it started.
Shortcomings in Medicare’s efforts to stop fraud, abuse and waste have come into focus since April, when the Centers for Medicare and Medicaid Services, the agency that runs the program, made public medical-provider billing records for the first time since 1979. The disclosure followed a legal effort by The Wall Street Journal.
CMS must strike a delicate balance: reducing fraud and abuse as much as possible without restricting access to medical care for the 50 million people who depend on the program. “Preventing fraud, abuse and waste are priorities” and “hold equal importance with creating and maintaining transparent and viable patient-doctor relationships,” CMS said in a written statement.
Fixing some of the system’s most pervasive problems—such as doctors billing for lots of procedures that may not be medically necessary—would require Medicare to change how it pays providers, some former Medicare officials said. That, in turn, would necessitate an act of Congress, they said.
Read the rest of the story HERE.

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