USA - MEDICARE TO HIRE SPECIAL ANTI-FRAUD CONTRACTORS

USA - MEDICARE TO HIRE SPECIAL ANTI-FRAUD CONTRACTORS

Ted A. Trower

3/17/1998

Date: March 17, 1998
For Release: Immediately
Contact: HCFA Press Office (202) 690-6145


Headline: MEDICARE TO HIRE SPECIAL ANTI-FRAUD CONTRACTORS
Announcement Highlights HCFA Conference on Fraud, Waste and Abuse

     HHS Secretary Donna E. Shalala today announced that Medicare
will begin hiring special contractors to fight fraud and abuse.

     We are determined to drive out the scam artists who are
stealing from the health care of seniors and the disabled, said
Shalala, who made the announcement at a Health Care Financing
Administration Conference on Fraud, Waste and Abuse.

     Now we can hire special contractors to help us fight fraud.
Fighting fraud and abuse is one of our highest priorities, and this
is another important tool we need to succeed, said Shalala. We
set records for convictions, collections and kicking bad providers
out of our programs in 1997, but we can and must do more.

     Medicare alone saved more than $7.5 billion through anti-fraud
and abuse efforts in fiscal 1997, and with its law enforcement
partners returned another $1 billion to the Medicare Trust Fund.
Efforts of the highly successful Operation Restore Trust anti-fraud
program identified $23 in money owed back to the Trust Fund for
every $1 spent on fraud detection and recoveries. Lessons learned
in that pilot project are now being applied nationwide.

     We are extremely eager to start using these new anti-fraud
contractors to further step up our fight against fraud, waste, and
abuse, said Nancy-Ann Min DeParle, Administrator of HCFA, which
runs Medicare. These contractors will work together with our
contractors who process claims, the HHS Inspector General, the
Department of Justice, and our other partners in fighting fraud,
waste and abuse.

     Until now, only insurance companies whose primary
responsibility is to process Medicare claims have been able to
conduct audits, medical reviews, and other activities that attack
waste, fraud and abuse. Under new authority provided by the Health
Insurance Portability and Accountability Act, Medicare is expanding
its contracting authority to include more firms from the private
sector who can bring new energy and ideas to this essential task.

     A new proposed regulation, on display at the Federal Register,
sets parameters for specific activities that special anti-fraud
contractors can undertake to protect Medicare and the taxpayers who
fund it. These include:

     medical reviews, to ensure that services billed to Medicare
     were medically necessary;
     cost report audits, to ensure that Medicare only pays for
     services and overhead costs that it is legally supposed to pay;
     secondary payer determinations, to ensure that Medicare does
     not pay bills for Medicare beneficiaries that should be paid by
     another insurer;
     provider and beneficiary education about what can and cannot be
     billed to Medicare, and how to spot and report potential fraud
     and abuse; and
     establishing a list of durable medical equipment, such as
     wheelchairs, that will require prior authorization before being
     billed to Medicare.

     There is a 60 day public comment period on the proposed
regulation. Medicare expects to publish a final regulation and
begin hiring these anti-fraud contractors as quickly as possible.

     DeParle also announced at the conference that Medicare is
stepping up efforts to address abuse of physician billing number
reassignment. Physicians sometimes have a legitimate need to
reassign billing numbers to clinics where they furnish care.
However, reassignment can be a source of abuse, with bills submitted
for care that is not provided or is inappropriate, and which the
physician knows nothing about.

     Targeted reviews of physicians in Florida with many
reassignment arrangements revealed situations where reassignment was
clearly being abused. Some clinics were submitting claims under
billing numbers of physicians who had not worked at their clinic in
more than two years. In other cases, claims were being submitted
for care provided by a single physician in a single day from clinics
that are hundreds of miles apart.

     Sen. Bob Graham and I personally visited clinics in Florida
where we saw how this kind of abuse had to be stopped, and I am
determined to do something about it, said DeParle.

     DeParle is directing that targeted reviews of physicians with
large numbers of reassignments be done nationwide. Medicare is
evaluating whether it should limit the number of reassignments a
physician can make or whether some other approach is necessary to
deter abuse. In addition, Medicare is stepping up enforcement of
existing rules requiring that physicians have information about what
is billed in their names.

     The Conference on Fraud, Waste and Abuse includes experts from
across the country who will discuss other new ideas for fighting
health care fraud and abuse.

     We need to keep working harder and smarter to catch criminals
who try to stay one step ahead of every loophole we close and every
scam we shut down, said DeParle. This conference will help us
learn how to build on our successes and develop a plan for doing
even more to protect consumers and taxpayers from health care scams
and unscrupulous providers.


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Note: HHS press releases are available on the World Wide Web at:
<URL Redacted>.

Ted A. Trower C.P.
A-S-C Orthotics & Prosthetics
Jackson, Michigan, USA
<Email Address Redacted>

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