June 1998 Bulletin

IG audit found errors, not fraud in Medicare claims

The Health Care Financing Administration (HCFA) appears to be playing "good cop, bad cop" at the same time. HCFA officials are trying to soothe the medical community about reports of multibillion dollars in "fraud and waste" in 1997 Medicare reimbursement claims, while being adamant that physicians must follow the rules.

At issue is an Inspector General's audit of 8,048 Medicare claims in 1997 that found 1,907 did not comply with Medicare rules and regulations. This was projected over the total amount of Medicare claims to produce $20.3 billion of what the media termed as "fraud and waste." The Associated Press reported that the auditors estimated improper payments in 1997 might be as high as $28.4 billion or as low as $12.1 billion.

Linda Ruiz, director, program integrity, assured physicians at the National Orthopaedic Leadership Conference April 30, that the government does not know how many of the 1,907 claims were fraudulent. The audit showed that half of the errors were due to inadequate documentation or incorrect coding and 3 percent due to lack of any documentation, she said. Some of the errors were due to upcoding.

In one case, the claim was submitted with one word, "stable." Another claim said only "bronchitis improving after taking medication."

While assuring the physicians that she understood their concerns and urging them to be diligent in their documentation, she also said, "stop whining and let's start working together." Ruiz said "the least of your worries should be that you will be prosecuted for fraud and abuse. You should be worried that the public believes there is a problem and that physicians are part of it." But some orthopaedic surgeons responded that HCFA was responsible for the impression that the physicians were guilty of fraud and abuse. Ruiz countered that HCFA had no control over how the media portrayed the results of the IG's audit.

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