Waste and Fraud

The Office of Inspector General (OIG) is asking for $10 million in additional funding in fiscal 2020 to target fraud, waste and abuse in home and community-based settings, with a focus on four geographic hotspots that OIG associates with “suspicious behavior” -- Florida, Texas, and select areas in Southern California and the Midwest.

Senate Finance Committee Chair Chuck Grassley (R-IA) and health subcommittee Chair Pat Toomey (R-PA) on Friday (March 8) lambasted CMA for failing to recoup improper Medicaid eligibility-related payments in excess of 3 percent made by states since 1992 and asked the agency to respond by March 15 on how they plan to fix the situation and whether they need Congress’ help to do so.

Senate Finance Committee Chair Chuck Grassley (R-IA) on Wednesday (Jan. 9) said he expects to spend time looking at Medicare and Medicaid waste, fraud and abuse now that he has resumed the chairmanship, along with health care anti-trust issues.

CMS said the most recent improper pay rates show that, for the first time since the data has been reported, improper payment rates went down in Medicare fee-for-service, Medicare Advantage, Medicaid and the Children’s Health Insurance Program, and the fiscal 2018 Medicare fee-for-service improper pay rate is at the lowest since the 2010 rate.

Two California men have pleaded guilty to conspiring to defraud Affordable Care Act plans in at least 12 states by enrolling people in coverage and transporting them to expensive drug treatment facilities in California that paid referral and other fees, the Department of Justice announced.

CMS is negotiating with inpatient rehabilitation facilities to potentially settle Medicare appeals, HHS says in a recent court briefing, and additional settlement meetings with the IRF lobby are expected in the upcoming months.

The HHS Office of Inspector General is asking for feedback on how to coordinate the anti-kickback and physician self-referral, or Stark, laws as well as how to set up safe harbors to help alternative pay models and the possibility of letting providers waive co-pays or provide other incentives to beneficiaries as a way to promote care engagement.

Home health providers question how CMS' revamped home health demonstration will help stem fraud when the agency has recognized the high improper pay rate in that sector appears to be driven largely by paperwork problems, and suggest CMS look at alternatives.

CMS should do more to oversee program integrity in Medicaid managed care, the Government Accountability Office said in a report released Thursday (July 26), the third report in two months by a government watchdog agency calling for greater supervision of Medicaid managed care.