Report Highlights Medicare FraudMost Payment Suspensions Related to Fraudulent Practices
"The great majority of providers that the Centers for Medicare & Medicaid Services suspended in 2007 and 2008 exhibited characteristics that suggest fraud," according to the report. "CMS recommends that providers suspended due to fraud receive no advance notice; in all but three of the suspensions, no such advance notice was given."
In analyzing the payment fraud, the report found that 74 percent of suspended providers showed questionable billing patterns. And 63 percent of suspensions were supported by information from beneficiaries or other providers, such as evidence that the suspended providers had billed for services that were never received or were medically unnecessary, the report found.
Other Medicare Report FindingsAmong other findings:
- Only 7 percent of overpayments were eventually collected.
- 85 percent of suspensions were for Medicare Part B providers, such as physicians, home health agencies and durable medical equipment dealers, with 15 percent for Part A providers (hospitals).
- 79 percent of the suspensions of billing privileges were in Florida, Puerto Rico, California and Michigan. A total of 35 percent of suspensions were in Florida alone.
New Fraud-Fighting ProvisionUnder healthcare reform, the Centers for Medicare & Medicaid Services, working in collaboration with the OIG, may suspend payments to a provider pending an investigation of a "credible allegation of fraud." Proposed regulations to carry out that provision are under final review.
Until healthcare reform was adopted, CMS could suspend payments to a Medicare provider only under three circumstances: fraud or willful misrepresentation; when an overpayment exists but the amount has not been determined; or when payments made are incorrect.