Sen­a­tors slam lack of Medi­care Ad­van­tage over­sight

Au­dit crit­i­cizes Medi­care Ad­van­tage watch­dog

Modern Healthcare - - NEWS - Joe Carl­son

Abipartisan group of sen­a­tors blasted the CMS about the level of over­sight in the $124 bil­lion Medi­care Ad­van­tage pro­gram af­ter HHS’ in­spec­tor gen­eral’s of­fice re­leased an au­dit report sug­gest­ing there’s very lit­tle.

“This report by the in­spec­tor gen­eral shows that we haven’t made enough progress in safe­guard­ing Medi­care by de­tect­ing and prevent­ing waste, fraud and abuse,” Sen. Tom Carper (D-Del.) said in a writ­ten state­ment.

The report last week found that the CMS’ out­side con­trac­tor in charge of root­ing out fraud in the Medi­care Ad­van­tage pro­gram ac­tu­ally opened far more in­ves­ti­ga­tions in a dif­fer­ent pro­gram it is sup­posed to mon­i­tor, Medi­care’s pre­scrip­tion-drug ben­e­fit, which costs slightly less than half what Medi­care Ad­van­tage does but was the sub­ject of about 80% of all the com­pany’s cases un­der the con­tract.

HHS au­di­tors also found that the con­trac­tor, Health In­tegrity of Eas­ton, Md., rarely un­cov­ers its own leads on po­ten­tial fraud in Medi­care Ad­van­tage, with proac­tive in­ves­ti­ga­tions rep­re­sent­ing 6% of the cases. The other 94% are based on out­side tips from ex­ter­nal sources.

The find­ings come af­ter HHS’ in­spec­tor gen­eral’s of­fice re­leased four au­dits last year doc­u­ment­ing pat­terns of ques­tion­able di­ag­noses con­tained in pa­tient files used to set pay­ment rates for Medi­care Ad­van­tage plans.

The four pre­vi­ous au­dits doc­u­mented $771,000 in ac­tual over­pay­ments in 400 ran­domly se­lected pa­tients’ files from 2007, and then went on to ex­trap­o­late an es­ti­mated $598 mil­lion in to­tal over­pay­ments were re­ceived that year by the four con­trac­tors, based on pat­terns in the sam­ple data.

Health In­tegrity, whose $28 mil­lion, twoyear con­tract with the CMS puts it in charge of dis­cov­er­ing such over­pay­ments, de­clined to com­ment be­cause a spokesman said the fed­eral con­tract for­bids pub­lic state­ments about the pro­gram.

While the CMS has over­lap­ping lay­ers of out­side con­trac­tors scour­ing Medi­care Parts A and B for fraud, the agency has only Health In­tegrity to look for prob­lems in Medi­care Part C (Medi­care Ad­van­tage) and Part D (the pre­scrip­tion-drug ben­e­fit).

Medi­care Parts C and D ac­count for $190 bil­lion in an­nual spend­ing, yet the au­dit of Health In­tegrity’s work found that it re­ferred only 245 cases to law en­force­ment for po­ten­tial pros­e­cu­tion be­tween April 2010 and March 2011. Of those, only 9% re­sulted from data anal­y­sis ini­ti­ated by Health In­tegrity.

“De­spite spend­ing more than $24 mil­lion over a two-year pe­riod, CMS’ con­trac­tor only dis­cov­ered through their own ini­tia­tive 21 cases of fraud that they re­ferred to law en­force­ment,” Sen. Tom Coburn ( R- Okla.) said in a writ­ten state­ment. “Given Medi­care Parts C and D’s $190 bil­lion in an­nual ex­pen­di­tures, CMS needs to be much more ag­gres­sive about de­tect­ing waste, fraud and abuse.”

A CMS of­fi­cial said in an e-mail that the agency has al­ready taken steps to im­prove en­force­ment, in­clud­ing giv­ing Health In­tegrity ac­cess to cen­tral­ized data on the Medi­care Ad­van­tage pro­gram and en­hanc­ing the firm’s re­port­ing re­quire­ments.

“CMS takes this report very se­ri­ously, and is com­mit­ted to en­sur­ing the in­tegrity of Medi­care Parts C and D through ef­fec­tive strong over­sight of [Health In­tegrity’s] work,” the CMS spokes­woman said in an e-mailed re­sponse to ques­tions. “Our goal is to en­sure peo­ple with Medi­care re­ceive qual­ity health­care while safe­guard­ing tax­payer dol­lars.”

The in­spec­tor gen­eral’s report noted other weak­nesses, in­clud­ing the fact that the com­pany does not have author­ity to pur­sue over­pay­ments if a law-en­force­ment agency like the FBI or a state agency de­clines to take the case.

In a writ­ten re­sponse to the au­dit in­cluded in the report, Act­ing CMS Ad­min­is­tra­tor Mar­i­lyn Taven­ner noted that any over­pay­ments that are de­tected in Medi­care Part C would ac­tu­ally go back to the health plans, rather than to the CMS.

Clare Krus­ing, a spokes­woman for in­dus­try trade group Amer­ica’s Health In­surance Plans in Washington, said the or­ga­ni­za­tion agrees with Taven­ner’s state­ments that Medi­care Ad­van­tage providers have a fi­nan­cial in­cen­tive to root out fraud in pa­tient med­i­cal records. In fact, the plans are re­quired to im­ple­ment com­pli­ance pro­grams to de­tect and pre­vent fraud and abuse, she wrote in an e-mail.

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