Medicare Improper Payments: Challenges for Measuring Potential Fraud and Abuse Remain Despite Planned Enhancements
T-AIMD/OSI-00-251
Published: Jul 12, 2000. Publicly Released: Jul 12, 2000.
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Highlights
Pursuant to a congressional request, GAO discussed the Health Care Financing Administration's (HCFA) efforts to improve the measurement of improper payments in the Medicare fee-for-service program.
Recommendations
Recommendations for Executive Action
| Agency Affected | Recommendation | Status Sort descending |
|---|---|---|
| Health Care Financing Administration | To improve the usefulness of measuring Medicare fee-for-service improper payments, including those attributable to potential fraud and abuse, the Administrator, HCFA, should experiment with incorporating additional techniques for detecting potential fraud and abuse into methodologies used to identify and measure improper payments and then evaluate their effectiveness. In determining the nature and extent of additional specific procedures to perform, the overall measurement approach should: (1) recognize the types of fraud and abuse perpetrated against the Medicare program; (2) consider the relative risks of potential fraud or abuse that stem from the various types of claims; (3) identify the advantages and limitations of common fraud detection techniques and use an effective combination of these techniques to detect improper payments; and (4) consider, in consultation with advocacy groups, concerns of those potentially affected by their use, including beneficiaries and health care providers. |
Closed – Implemented
Since GAO reported, the Centers for Medicare and Medicaid Services (CMS), formally know as HCFA, has experimented with various techniques for detecting potential fraud and abuse, including those identified by GAO as considered effective by health and fraud investigative experts. Specifically, CMS implemented the Statistical Analysis Center (SAC) pilot, a 2-year project ending in March 2002, that employed experts in statistical analysis to create a database of all claims for beneficiaries residing in three states and experiment with applying data mining, data sharing, and other innovative techniques to identify suspicious claims. According to CMS, the SAC pilot identified about $38 million in suspicious claims and demonstrated the benefit of applying statistical analysis to assess whether or not a potential pattern of abuse exists. As a result of the SAC pilot, CMS has gained experience with additional techniques that it can incorporate into its measurement methodologies to improve its analysis of underlying causes of improper payments and enhance future fraud and abuse detection.
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| Health Care Financing Administration | To improve the usefulness of measuring Medicare fee-for-service improper payments, including those attributable to potential fraud and abuse, the Administrator, HCFA, should include in the methodologies' design, sufficient scope and evaluation to more effectively identify underlying causes of improper payments to develop appropriate corrective actions. |
Closed – Implemented
See related report (AIMD/OSI-00-281) for same recommendation. The Centers for Medicare and Medicaid Services (CMS) had planned to implement a Model Fraud Rate Project, designed to test the viability of identifying and measuring Medicare claims attributable to fraud and abuse. However, due to budget constraints, CMS has not implemented this project. CMS has however, created databases of sampled claims from its Comprehensive Error Rate Testing (CERT) program. CERT was established to produce an error rate for carriers, Durable Medical Equipment contractors (DMERCS), and fiscal intermediaries claims. The sampled claims can be used to evaluate underlying causes of improper payments including those claims that were paid incorrectly because of fraud and abuse. For example, CMS estimated that improper payments for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS), were over $900 million in fiscal year 2004. CMS pays contractors to investigate suppliers and help determine the extent to which improper payments are due to fraud and abuse. Contractors have developed some cases that have been referred for law enforcement and prosecution. These actions have helped CMS in understanding the causes of payment errors including those attributable to fraud.
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Topics
Claims processingCost effectiveness analysisFraudHealth insuranceHealth insurance cost controlInternal controlsMedicareOverpaymentsPerformance measuresProgram abusesProgram evaluation