In the ongoing effort to protect the Medicare program, deterrence stands out as a powerful and cost-effective strategy. While detection and enforcement remain critical, deterrence shifts the focus from reacting to fraud after it occurs to preventing it before it starts. By increasing the perceived risk of getting caught and reducing opportunities for abuse, deterrence…
Medicare
Suspect Payments in Medicare Advantage: Why Transparency Matters
Understanding the context of “Suspect Payments” In Medicare Advantage, payment practices work best when they are clear, consistent, and aligned with beneficiary needs. Strengthening oversight not only reduces compliance risk but also reinforces trust in an organization’s commitment to doing what’s right. Medicare Advantage payment structures can be complex, and certain arrangements may warrant closer…
Medicare’s $60 Billion Challenge
Medicare loses an estimated $60 billion annually to fraud, waste, and abuse (FWA), a serious drain on critical health resources that directly affects the care and well-being of millions of beneficiaries. These losses not only compromise the integrity of the program but also erode public trust in one of our nation’s most essential public health…
Exposing Hidden Risks: A Strategic Approach to FWA in Medicare Advantage
Medicare Advantage (MA) has reshaped healthcare coverage for beneficiaries, offering comprehensive benefits through private insurers. However, the program’s expansion has also introduced complex challenges, notably fraud, waste, and abuse (FWA) that threaten its integrity and the well-being of beneficiaries. The Challenge Recent investigations have uncovered concerning practices within the MA landscape. Some Medicare Advantage Organizations…
Beyond Coverage: How Medicare and Medicaid Transform Public Health
Did you know that Medicare and Medicaid, established in 1965 under President Lyndon B. Johnson, have profoundly influenced public health in the United States? Initially designed to provide health insurance to seniors and low-income individuals, these programs have expanded access to care, reduced health disparities, and set quality standards that shape the entire healthcare system.…
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How the Inflation Reduction Act will impact Medicare drug prices
The signing of the Inflation Reduction Act in August of 2022 brought some immediate relief for Americans with Medicare prescription drug coverage and will continue to drastically impact drug prices as implementation continues. Already in effect as of January 2023: a $35 cap per month on insulin for Medicare prescription plan enrollees, Medicare beneficiaries receive…
Signs of Fraud in Payment Arrangements!
Fraud in Medicare Advantage often operates under the radar, but relationships or subtle patterns can reveal its presence. To uphold program integrity, look beyond obvious data anomalies and consider these critical warning signs: Unusual referral patterns between providers/suppliers Frequent turnover of enrollment agents Unexpected spikes in plan-switching behavior At IntegrityM, we recognize that effective fraud…
Efficiently Evaluating “Big Data” for Medicare Fraud Detection
With over 2 billion Medicare claims available for analysis since 2006, the term “Big Data” has no better application than in the health care industry. The opportunity for meaningful analyses resulting from big data is limitless. However, finding the best method for combing through Medicare claims data in an efficient manner can be tricky since…
Understanding the Telehealth Claims Landscape
Telehealth is expanding rapidly and transforming healthcare. According to the Medicare Payment Advisory Commission, the number of telehealth visits grew by over 500 percent from 2008 to 2014. Additionally, many commercial insurers cover — and many health systems offer — a variety of telehealth services. The industry has seen impressive advancements in telehealth technology, and…
Improper Payments Elimination and Recovery Act: Identifying and Reducing Improper Payments
Each year, the Federal Government makes billions of dollars in improper payments. Improper payments can take the form of overpayments, payments to the wrong person, or payments for the wrong reason. Two examples of improper payments include the Federal Government paying $180 million to 20,000 dead individuals over a three-year period, as well as paying…
Network Adequacy: Meeting Requirements and the Impact of the ACA
The Affordable Care Act directed the Secretary of Health and Human Services to establish criteria for certification of qualified health plans, to include (1) ensuring a sufficient choice of providers and (2) providing information to enrollees and prospective enrollees on the availability of in-network and out-of-network providers. 45 CFR 156.230, entitled network adequacy standards, requires qualified…
Medicaid Health Homes Program Operation
Section 2703 of the Affordable Care Act created an optional Medicaid State Plan benefit – Health Homes – to coordinate care for individuals who have Medicaid and have: 2 or more chronic conditions; 1 chronic condition and are at risk for a second; or 1 serious and persistent mental health condition. Chronic conditions include substance…
Healthcare Secret Shopping: An Effective Tool for Detecting Fraud and Abuse
The Government Accountability Office (GAO) made headlines recently when sharing news that 11 of 12 fictitious applicants obtained coverage for health insurance through the Federal marketplace. GAO targeted the Federal marketplace with secret shopping – constructing fictitious applicants who should not have received health insurance. The secret shopping applicants provided invalid Social Security information or…
Ambulance Billing Fraud and False Claims
Medicare ambulance claims, just like everything involved with Medicare, must meet certain requirements to be considered valid ambulance transport claims. The main factor is the transport must be considered “medically necessary” under Federal Law. To do this, two specific criteria must be met: The use of other transportation methods is contraindicated by the condition of…
Inappropriate Medicare Payments for Chiropractic Services More Common than Other Services
In May 2015, the U.S. Department of Health and Human Services Office of Inspector General (OIG) issued a report finding all claims for the provider under review failed to support medical necessity. OIG concluded virtually all payments the provider received were unallowable. Why were all payments not identified as unallowable? OIG used a sample and…
Electronic Health Record Challenges: A Look at EHR Fraud, Security Issues, & Adoption Barriers
Since the late 20th to early 21st century, reports such as “To Err is Human” by the Institute of Medicine have been published and have advocated the adoption of electronic health records (EHRs). EHRs offer tools to mitigate human error, be a medium to share personal medical records securely across the country, establish electronic communications…
Medicaid Managed Care Audits Pay Off…In the Long Run
In May 2014, the Government Accountability Office (GAO) released a report calling for increased oversight of Medicaid managed care spending (the report can be found here). GAO reported that “Most state and federal program integrity officials we interviewed told us that they did not closely examine Medicaid managed care payments, but instead primarily focused their…
Improving Healthcare Error Reporting In Healthcare Audits
The purpose of this paper is to offer a technique to more clearly and fully describe healthcare errors detected in audits, which can lead to improved return on investment (ROI) for healthcare audits. A clear and complete description of all identified errors in a healthcare audit report will help assure that all readers of the…
Peeling the Onion: Achieving More Significant Results by Digging Deeper into CMS Payment Data
The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) issued an audit report to the Centers for Medicare & Medicaid Services (CMS) in February 2015 that illustrates how an audit team can achieve more significant results by simply digging deeper. The report entitled CMS Made Payments Associated With Providers After…
Why Does Medicare Allow Hospitals to Bill for Kwashiorkor?
On March 6, 2015, the U.S. Department of Health and Human Services Office of Inspector General (OIG) released the latest in a series of reports looking at hospitals’ billing and Medicare paying for Kwashiorkor. For those new to Kwashiorkor, Kwashiorkor is a form of severe protein malnutrition that generally affects children living in tropical and…
