October 2001 Bulletin

HHS actions, protests rise

GAO examines serious fraud/abuse charges by physicians

Administration, now known as the Centers for Medicare and Medicaid Services, have increased significantly since 1977, and so have complaints of physicians and medical associations.

By 2003, funding for antifraud and abuse activities known as the Medicare Integrity Program (MIP) will have grown about 80 percent. In fiscal year 2000, HCFA used $630 million in MIP funding to support a wide range of efforts, including audits of provider and managed care organizations and targeting medical review of claims.

In a report to the Senate Special Committee on Aging in July, the General Accounting Office said physicians and medical associations have made a number of serious charges. Leslie G. Aronovitz, director, health care program administration and integrity issues, listed the following concerns.

Inadequate communications from CMS’ contractors. Providers assert that information they receive is poorly organized, difficult to understand and not always communicated promptly. As a result, providers are concerned that they may inadvertently violate Medicare billing rules.

Inappropriate targeting of claims for review and excessive paperwork demands of the medical review process. For example, some physicians have complained that the documentation required by some contractors goes beyond what is outlined in agency guidance or what is needed to demonstrate medical necessity.

Unfair method used to calculate Medicare overpayments. Providers expressed concern that repayment amounts calculated through the use of samples that are not statistically representative do not accurately represent actual overpayments.

Overzealous enforcement activities by other federal agencies. For example, providers have charged that the Department of Justice has been overly aggressive in its use of the False Claims Act and has been too accommodating to the Office of the Inspector General’s insistence on including corporate integrity agreements in provider settlements.

Lengthy process to appeal denied claim. Related to this issue is that a provider who successfully appeals a claim that was initially denied does not earn interest for the period during which the administrative appeal was pending.

Aronovitz said the GAO said it is examining how claims are reviewed and how overpayments are detected to assess the actions of contractors. Although the GAO has not yet formulated its conclusions, Aronovitz said actions already taken by HCFA may address some provider concerns. For instance, HCFA clarified conditions under which contractors should conduct medical reviews of providers. HCFA also outlined procedures to give providers several options to determine overpayment amounts.

Other actions reviewed by Aronovitz include guidance issued by the Department of Justice to its attorneys emphasizing the fair and responsible use of the act in civil health care matters.

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