Agencies Team Up to Reduce Medicare Fraud

In response to President Barack Obama’s recent request for the U.S. Department of Health and Human Services (HHS) to cut the Medicare fee-for-service program’s improper payment rate in half by 2012, HHS and the U.S. Department of Justice (DOJ) are stepping up efforts to detect and discourage Medicare and Medicaid fraud and abuse. Although the current focus is on safeguarding seniors from Medicare scams, legitimate health providers can expect added scrutiny from auditors looking for unsubstantiated claims.

DOJ Attorney General Eric Holder and HHS Secretary Kathleen Sebelius are joining forces again, asking federal, state, and local law enforcement officials to help them mount an outreach campaign, beginning this summer.

In a June 8 letter to state attorneys general, Holder and Sebelius say they “will use the new tools and resources provided by the Affordable Care Act to further crack down on fraud.”

The letter outlines steps the departments intend to take under the campaign, including regional fraud prevention summits around the country over the next few months. The first summit will take place July 16 in Miami. Others will be held in major metropolitan areas such as Los Angeles, Las Vegas, Detroit, Boston, New York City, and Philadelphia.

These summits will bring together top federal and state officials; representatives of federal, state, and local law enforcement; agency representatives; the health care provider community, such as hospitals and doctors; local businesses; the Senior Medicare Patrol; caregivers; and seniors, for a day of panels and training sessions.

The provider community, however, may be better served to arm themselves against increasing government audit activity. Internal audits and improved documentation are generally recommended.

In Part 2 of a two-part interview with Lise Rauzi, vice president of Training Development for Health Care Compliance Strategies, Inc. (HCCS), David Rosenthal, MD, vice president of Strategy and Marketing for HCCS, asks Rauzi why a lot of the auditing activity seems to focus on documentation.

Rauzi responds, “The point organizations and physicians need to understand is that they may be delivering the standard Quality of Care (QOC), but it may not be documented in a way that an auditor can easily follow. If it’s not transparent in the documentation as to what went on and why things were done, they are going to disallow the payment.”

“To increase the odds of favorable audits, much more is needed in histories and clinical impressions. It is no longer enough to just write down what the diagnosis was. Detail about the status of the condition will be required. For example, was the condition acute or chronic on the date the patient was seen? If it was chronic, was it stable or unstable? Are there any other conditions that played a role in the patient’s status and had to be evaluated?”

Read the rest of Rosenthal’s interview with Rauzi on the HCCS website.


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