WASHINGTON, D.C. – The U.S. Department of Health and Human Services (HHS) reported an estimate of nearly $48 billion in improper Medicare payments during the 2010 fiscal year, or approximately 38 percent of the total $125.4 billion estimate for the entire federal government, according to a summary of testimony recently delivered by representatives with the U.S. Government Accountability Office (GAO) – but officials labeled even that lofty estimate “incomplete” because HHS has yet to develop a comprehensive projection for the Medicare prescription drug benefit.
The GAO has made a series of recommendations intended to help the Centers for Medicare & Medicaid Services (CMS) strengthen its ability to prevent or detect and recoup improperly distributed reimbursements, officials announced last week. Those recommendations were unveiled as part of GAO testimony delivered before the U.S. House of Representatives Subcommittee on Government Organization, Efficiency and Financial Management, which is part of the House’s Committee on Oversight and Government Reform.
“It is important to recognize that the $48 billion is not an estimate of fraud in Medicare,” the summary noted. “Because the improper payment estimation process is not designed to detect or measure the amount of fraud that may exist, there may be fraud that is not reflected in HHS’s reported estimate.”
The GAO cited inadequate documentation, medically unnecessary services, coding errors and payment calculation errors as several causes for the improper payments, noting that CMS is facing challenges in designing and implementing internal controls to prevent or detect and recoup improper payments. In 2010, CMS established the Center for Program Integrity to serve as its focal point for all national Medicare integrity issues, and based on past work, the GAO identified five key strategies to help reduce fraud, waste and abuse in Medicare.
The recommendations outlined last week are intended to help strengthen CMS’s implementation of those strategies, some of which the agency has yet to implement at all, officials explained. The recommendations are as follows:
The GAO in the past has designated Medicare as a high-risk program because of its size, complexity and susceptibility to improper payments. In 2010, Medicare covered 47 million elderly and disabled beneficiaries, with estimated outlays of $516 billion. The GAO based its testimony on updated information received from CMS in February 2011, and in select cases, as of July 2011, on its actions related to relevant laws, regulations, guidance and open recommendations pertaining to key remediation strategies.
Mark Spivey is a correspondent for the RACmonitor.com and ICD10monitor.com websites.