Health Care Fraud and Abuse: Hearing Before the Human Resources and Intergovernmental Relations Subcommittee of the Committee on Government Operations, House of Representatives, One Hundred Second Congress, Second Session, May 7, 1992
United States. Congress. House. Committee on Government Operations. Human Resources and Intergovernmental Relations Subcommittee
U.S. Government Printing Office, 1993 - 172 pages
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action activity ADDITIONAL administrative agencies agents Appendix Association Attorney beneficiaries billing billion Chairman claims commission concerns CONG CONGRESS THE LIBRARY contractors COORDINATION costs crime criminal deal detection developing doctors dollars effective efforts equipment establishing example facilities false False Claims Act Federal fraud and abuse fraudulent health care fraud health care providers health insurance hearing HOSPITALS Human identify increase industry Inspector insurance companies interest investigative involved issues kind LABORATORY labs law enforcement LIBR LIBRA LIBRARY OF CONGRESS limited look Lose Medicaid Medicare Office operating organized patients payers PAYMENT percent physicians practice prevention private insurers problem programs prosecution providers questions records recovered referred regulations representative result scheme share SHIKLES staff statutes submitted tests Thank things THOMAS United Vulnerable WEISS
Page 152 - 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 10 - ... billing practices that include misrepresenting or overcharging with respect to services delivered. Both result in unnecessary costs to the insurer, but fraud generally involves a willful act, whereas abuse typically involves actions that are inconsistent with acceptable business and medical practices. 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...
Page 137 - 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. Finally, schemes can be quickly replicated throughout the health care system.
Page 4 - Despite the commonality of fraud and abuse problems, diverse and autonomous insurers have few means of collaborating systematically to solve them. In our view, if the efforts of independent private payers, public payers, and state insurance and licensing agencies as well as state and federal law enforcement agencies were more coordinated, the attack on health care fraud and abuse would be more fruitful.
Page 162 - Fraud and Abuse: Stronger Controls Needed in Federal Employees Health Benefits Program (GAO/OGD4I-86, July 1991).
Page 162 - Medicare Claims Processing: HCFA Can Reduce the Disruptions Caused by Replacing Contractors GAO/HRD-91-44 Apr.
Page 5 - Mr. Chairman, this concludes my statement, and I would be happy to answer any questions you may have.
Page 95 - ... SOLELY TO INCREASE PROFITS. OTHERS HAVE DEVELOPED SCHEMES WHICH, COUPLED WITH MODERN TELEPHONE TECHNOLOGY, MAKE IT APPEAR THAT THEY ARE LOCATED IN AREAS THAT EITHER PAY A HIGHER REIMBURSEMENT RATE, HAVE THE LEAST RESTRICTIVE COVERAGE GUIDELINES, OR BOTH. WE HAVE RECOMMENDED THAT HCFA CHANGE THE RULE CONCERNING THE POINT OF SALE. THIS CHANGE WOULD REQUIRE THAT PAYMENT BE MADE BY THE CARRIER SERVICING THE AREA IN WHICH THE BENEFICIARY RESIDES. WE ARE PLEASED THAT IN A PROPOSED NOTICE OF RULEMAKING...
Page 151 - A recent effort to trim administrative costs coincides with the need for uniform data and signals the potential for coordinating the efforts of independent private insurers with public payers. In November 1991, the Secretary of HHS convened a Forum on Administrative Costs composed primarily of major private health insurers. The goal of the forum was to discuss a national strategy for streamlining the costs of administering health insurance. In doing so, the forum proposed administrative reforms that...