Mid-Atlantic Health Law TOPICS

June Gibbs Brown, the Inspector General of the U.S. Department of Health and Human Services, recently reported to Congress on the agency's efforts to eliminate fraud and abuse in the Medicare program.

Ms. Brown explained that, although recent audits showed that improper Medicare payments had been reduced, there remained a number of problems requiring compliance activity. The following items were highlighted:

• The number one culprit resulting in improper Medicare payments is the lack of medical necessity for services rendered and billed to the program. The OIG has recently issued a "fraud alert," warning physicians that they will be held accountable for improper medical necessity determinations, even though the care in question is performed and billed by other health care providers.
• The second most important issue is incorrect coding. The OIG believes that a large percentage of Medicare billings cannot be supported at the level billed by the provider's records. Ms. Brown reported that documentation errors are on the decline, thanks to provider education efforts, but that such errors still often occur.
• Another major concern is unscrupulous providers who conduct "gang visits" at nursing facilities, where bills are submitted for every resident, regardless of whether the residents needed or even received the services. Previous fraud alerts have warned nursing facilities of their liability should they allow such practices to occur.
• The last item addressed was "uncovered services." The HCFA representative testified that billing for uncovered services was on the decline, but has not been eliminated as a problem.