Medicare Anti-Fraud Accountability May Be Lacking


Accountability is the keystone of everything from relationships to businesses, and once it’s gone, it can be hard to gain back. While all’s not lost within Medicare’s anti-fraud program, its accountability has taken a hit courtesy of a recent report from the Health and Human Services Office of Inspector General.

The Centers for Medicare & Medicaid Services didn’t have a way to track program savings associated with Fraud Prevention System efforts, the report said, and didn’t ensure that the savings reflected billing issues detected by the FPS. The FPS was rolled out in 2011 and incorporates predictive analytics and pre-payment audits to stop improper payments from ever being made.

However, the lack of accountability may simply indicate how hard it is to calculate the value of deterrence, Ellyn Sternfield, a health-care attorney with Mintz, Levin, Cohn, Ferris, Glovsky and Popeo PC in Washington, told me.

“When I ran my MFCU [Medicaid Fraud Control Unit], I often said I knew my program budget, and I know how much my team obtained in civil and criminal judgments, but I couldn't tell you how much fraud our team prevented by the public knowledge of my unit's investigation and enforcement activities,” Sternfield said.

Sternfield said a single-minded focus on improving a program’s return on investment (ROI) doesn’t always equate with success. For example, if the FPS flags some irregularities that turn out to be billing errors and not fraud, that information can be useful to the CMS even though it wouldn’t improve ROI, Sternfield said.

Read my full article here.

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