How Successful are Medicare Fraud Busting Efforts?

April 25, 2012

Based on provisions in the Affordable Care Act, over the last two years CMS has stepped up its efforts to root out and prevent Medicare fraud with measures that include stronger penalties, enhanced provider screening and enrollment requirements, improved fraud prevention coordination and new high tech tools. This post takes a look at the success of those efforts so far.

Anti-fraud efforts by the Health Care Fraud Prevention and Abuse Control (HCFAC) recovered over $4 billion during 2011, and nearly $11 billion over the past three years. In February of 2012 the Medicare Fraud Strike Force busted a $375 million health care fraud scheme, arresting a Dallas area doctor, office manager, and five owners of home health agencies for their alleged participation.

Other accomplishments include:

  • Charged 323 defendants who allegedly billed Medicare for over $1 billion
  • Charged 1,430 defendants with health care fraud and convicted 743
  • Recovered approximately $2.4 billion under the False Claims Act (FCA) in 2011

Seniors on Patrol Against Fraud

CMS is bringing seniors into the effort to control fraud too. In November of 2011 CMS awarded $9 million to the Senior Medicare Patrol (SMP) program to help it continue the fight against Medicare fraud. The SMP program has 5,000 volunteers across the nation. The funds will help seniors learn how to prevent, detect, and report health care fraud.

According to CMS, “the SMP volunteers work in their communities to educate Medicare beneficiaries, family members, and caregivers about the importance of reviewing their Medicare notices, and Medicaid claims if dually-eligible, to identify errors and potentially fraudulent activity.”

Since the program began in 1997, more than 25 million people have participated in community outreach education events, and over 4 million Medicare beneficiaries have received education in one-on-one counseling sessions.

High-Tech Tools

In 2011 CMS added high-tech tools to help it “crack down on waste, fraud and abuse.” In June of 2011 CMS announced that it would begin using predictive modeling technology, similar to technology used by credit card companies, to identify potentially fraudulent Medicare claims and prevent them from being paid. The new tools will help CMS move from its former “pay & chase” approach to one that focuses on preventing fraud and abuse before it takes place.

Visit Extend Health to use the ExtendExchange™ platform – the nation’s largest private Medicare exchange.

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