Pursuant to a congressional request, GAO reviewed allegations of fraud and abuse related to services and supplies provided to nursing facility patients, focusing on: (1) the nature and extent of such fraud and abuse exist; (2) why nursing facility patients are an attractive target for miscreants; and (3) options for reducing fraudulent billing practices.
Matter for Congressional Consideration
|To curtail the practice of giving providers unauthorized access to beneficiary medical records, Congress should authorize the Health and Human Services Office of Inspector General to establish monetary penalties that could be assessed against nursing facilities that disclose information from patients' medical records not in accord with existing federal regulation.||Section 1177 of the Health Insurance Portability and Accountability Act of 1996 (signed by President Clinton on August 21, 1996) provides that any person who obtains individually identifiable health information relating to an individual or discloses individually identifiable health information to another person shall be fined no more than $50,000, imprisoned not more than 1 year, or both. The penalties increase if the offense was committed under false pretenses or with intent to sell, transfer, or use such information for commercial advantage, personal gain, or malicious harm. This legislative change addresses the issue in a broader context than just nursing facilities releasing data from individual medical records.|
Recommendations for Executive Action
|Department of Health and Human Services||1. The Secretary of Health and Human Services (HHS) should direct the Administrator, Health Care Financing Administration (HCFA), to establish, for procedure billing codes by provider or beneficiary, thresholds for unreasonable cumulative levels or rates of increase in services and charges, and to require Medicare carriers to implement automated screens that would suspend for further review claims exceeding those thresholds.|
|Department of Health and Human Services||2. The Secretary of HHS should direct the Administrator, HCFA, to undertake demonstration projects designed to assess the relative costs and benefits of alternative ways to reimburse nursing facilities for Part B services and supplies. These alternative should include such options as unified billing by the nursing facility and some form of capped payment.|