Health Insurance: Vulnerable Payers Lose Billions to Fraud and Abuse : Report to the Chairman, Subcommittee on Human Resources and Intergovernmental Relations, Committee on Government Operations, House of Representatives
The Office, 1992 - 34 pages
ability abusive providers actions activities administrative agencies Association assurance beneficiaries billing Billions to Fraud Blue budget carriers cause centers civil claims claims processing collaborative commission complaints concerns considerable contractors costs criminal Department detection developing difficult effect efforts establish example facilities federal fiscal Fraud and Abuse fraudulent health care fraud health insurance fraud hospital Human identify inappropriate increased Inspector insurance companies interest investigative investment involved issues kickbacks laboratories labs licensing limited losses Management Medicare and Medicaid National Health Office operations patients Payers Lose Billions payment percent physician ownership physicians plans potential practices private insurers private payers problems processing prosecution prosecutorial providers pursuing pursuit recover reduce referrals regulation relating responsible result rolling-labs safeguards scheme sector share single spending statutes tests types Units unnecessary Vulnerable Payers Lose
Page 18 - Council recommends that, in general, physicians should not refer patients to a health care facility outside their office practice at which they do not directly provide care or services when they have an investment interest in the facility.
Page 32 - GAO report on contractors' performance in fiscal years 1983-87 includes data relating to (1) Medicare claims processing times and accuracy; (2) review of appealed claims cases; (3) processing of hearings related to appealed claims; (4) written, telephone, and walk-in inquiries by beneficiaries and providers; and (5) education of beneficiaries and providers about Medicare coverage and requirements. Medicaid: Improvements Needed in Programs to Prevent Abuse (GAO/HRD-87-75, Sept. 1987). GAO evaluated...
Page 3 - Schemes of this nature highlight several serious problems facing public and private payers. First, large financial losses to the health care system can occur as a result of even a single scheme. Second, fraudulent providers can bill insurers with relative ease. Third, efforts to prosecute and recover losses from those involved In the schemes are costly.
Page 28 - July 1991). Fraud and abuse controls in the Federal Employees Health Benefits Program were reviewed. GAO recommended changes to internal controls and program oversight that would minimize vulnerability to fraud and abuse. Medicare Claims Processing: HCFA Can Reduce the Disruptions Caused by Replacing Contractors (GAO/HRD-SI-M, Apr.
Page 2 - Frequently cited fraudulent or abusive practices include overcharging for services provided, charging for services not rendered, accepting bribes or kickbacks for referring patients, and rendering inappropriate or unnecessary services.
Page 4 - Thus the provider who bills for more than 24 hours of visits on a single day might not be discovered when claims are split among many insurers.
Page 24 - It will take some time, however, to hire and train these staff and thus to implement expanded safeguard programs. The Inspector General also cites resource constraints as a major impediment to investigating and pursuing many types of fraud and abuse. For example, the Deputy Inspector General stated that his office's responsibility for enforcing civil monetary penalty statutes has substantially increased to more than 80 statutes in recent years. The number of Inspector General investigators has remained...
Page 4 - Physicians frequently invest in medical facilities but are not always required to disclose their investment in facilities to which they refer patients. (See app. I. p. 19.) Anti-kickback statutes are not always applicable to providers profiting under private insurance from their patient referrals. (See app. I, p. 19.) Problema with Prosecuting Fraud and Abuse Successful prosecutions may not result in insurers recovering their money.
Page 1 - Human Resources Division B-246412 May 7, 1992 The Honorable Ted Weiss Chairman, Subcommittee on Human Resources and Intergovernmental Relations Committee on Government Operations House of Representatives Dear Mr. Chairman: The size of the health care sector and sheer volume of money involved make it an attractive and relatively easy target for fraudulent and abusive providers. Expected to total nearly $700 billion in 1991, health care spending will consume over 12 percent of our gross national product;...
Page 2 - ... include overcharging for services provided, charging for services not rendered, accepting bribes or kickbacks for referring patients, and rendering inappropriate or unnecessary services. Both fraud and abuse result in unnecessary costs to the insurer, but fraud generally involves a willful act. As a practical matter, whether and how a wrongful act is addressed can depend on the size of the financial loss incurred and the quality of the evidence establishing Intent. For example, small claims are...