Medicare Fraud and Government Inaction

I just finished reading the complete 2007 report from the Office of Inspector General of the Department of Health and Human Services entitled ABERRANT BILLING IN SOUTH FLORIDA FOR BENEFICIARIES WITH HIV/AIDS.

The reports opens with the following finding:

" In the last half of 2006, three South Florida counties accounted for half the total amount, and 79 percent of the amount for drugs, billed nationally for Medicare beneficiaries with HIV/AIDS. Most of the charges originating in these counties were for nonoral drugs; drug claims represented just 16 percent of the submitted charges in other geographic areas. Aberrant claims patterns differentiated South Florida providers and beneficiaries from those in the rest of the country."

"CMS has had limited success in controlling the aberrant billing practices of South Florida infusion therapy providers. CMS and its contractors have used multiple approaches, but none has proven effective over time. The most common tools include payment suspensions, revocations, and claims-processing edits. CMS has taken limited action to strengthen the enrollment process for new providers. "


A series for recommendation are being made and the report summarizes its findings as follows:

"CMS’s positive response to our recommendations, including its initiation of the new demonstration project, indicates that the agency is now moving toward strategies that should more effectively protect the integrity of Medicare payments in South Florida."

How do they define "success":

"Although billing increased from $1.5 to $3.3 Billion (CY 2004-2006) ,Medicare payments in Florida dropped from $1 Billion to $890 Million ... as a direct result of CMS' containment efforts."

Hardly a success story to me! Recent CMS data suggest that the "successful" containment efforts succeeded to contain as much (or little) as before.
Guess what; the party continues and First Coast Service Options continues to pay!

So, they nickle and dime good doctors and impose arbitrary 100% prepayment review requirements BUT allow crooks to sail a cruiseship through their loopholes.
How do I call it? Incompetence, negligence and stupidity. Maybe even more?

Yes, we need more third party oversight of the largest CMS contractor, First Coast Service Options, operations. As a contractor they should be scrutinized by Congress. But maybe there is too much money involved and too many people may loose their job financed by taxpayers money.
Or maybe I am just paranoid and should let it go.I don't think so.



Bernd