Senate Finance Committee takes fraud reduction suggestions
Five members of the Senate Finance Committee, including outgoing Montana Senator and Affordable Care Act architect Max Baucus, say they plan to draft policy proposals for reducing Medicare and Medicaid fraud and abuse based on input from more than 100 healthcare organizations.
The Senate Finance Committee's publication of stakeholder input comes after the Department of Health and Human Services proposed increasing rewards for successfully reporting Medicare fraud to $9.9 million -- after 2012 saw $63 billion in improper Medicare and federal Medicaid payments (not counting state Medicaid spending on improper billing).
Just how much of that $63 billion represents fraud isn't clear, and rarely has been. But either way, the Senate Finance Committee members want to "improve federal efforts to combat waste, fraud and abuse" in Medicare and Medicaid, at a time when federal spending, particularly on healthcare, is a central dispute in Washington.
Ahead of the committee's recommendations, the members released an overview of 164 comments and suggestions on program payment integrity, with most focused in the areas of improper payments, audit burdens, enforcement, data management and beneficiary protection.
Eighty-seven of the comments urged committee members to modify current improper payment policies. Some suggested offering incentives for investments in fraud-prevention -- with some providers and several insurers urging lawmakers to revise the ACA's medical loss ratio to include fraud prevention.
Some urged scaling up fraud prevention programs that would focus on high-risk providers and high-cost services, such as durable medical equipment or prescription drug abuse and the practice of "doctor shopping" by opioid users who try to obtain multiple painkiller prescriptions from different doctors.
Others recommended improving payment policies and guidance through best practice requirements, bundled payments, a simplified process for returning overpayments and simplified compliance for payment documentation. Specifically, some suggested "reducing the volume and complexity of Medicare rules to reduce the portion of improper payments due to technical errors and honest mistakes" and "making Medicare rules easily available from a central location, instead of from the various manuals and agency websites."
About a dozen organizations and stakeholders commenting on enforcement largely agreed that there should be better coordination between the at-times tangled web of state and federal agencies investigating and enforcing Medicare and Medicaid fraud, abuse or improper payments.
Specifically, some called for strengthening public-private partnerships by implementing and funding a 1997 Justice Department directive on cooperation and information sharing between private organizations and public agencies, as well as encouraging states to upgrade their monitoring programs.
Some insurance representatives suggested that prosecutors should be able to include amounts lost to fraud or abuse by commercial plans in their enforcement, "which is likely to allow federal and state prosecutors to seek and obtain even larger penalties against those who commit fraud by exposing the scope of the crime."
Others also called for a central repository of fraud and abuse cases; although HHS, CMS and DOJ do work together on prosecutions, they maintain separate databases of cases and may not retain the same information.
And 11 of the 164 commenters suggested increasing existing fines and penalties, with mostly providers and insurers suggesting the committee strengthen the Stark "anti-kickback" law, while a handful of others suggested HHS and DOJ look to cast as wide an anti-fraud and -abuse net as possible, to "pursue more cases and not only the "big fish."
