The Problems and Importance of Reporting Medicare Fraud

Reporting Medicare fraud helps protect and maintain not only the original medical practice involved, but all other practices around the country. State-to-state communication has been convoluted and not as closely monitored and, up until the Affordable Care Act (ACA) in 2010, fraudulent doctors who have billed inappropriately have continually slipped through the net of reporting Medicare fraud. This can occur due to procedural error or a lack of follow-through by individual practices. After all, once the fraudulent party has been removed, it appears as though he or she is no longer a risk. The fraud also continues due to inadequate state and federal data and communication.

The ACA explicitly denotes that a state must suspend the billing privileges of providers who have been terminated or revoked by another state. And yet, approximately one in five of these cases has shown that doctors and health care providers previously prohibited from billing federal Medicare are still able to bill state Medicaid. In 2014, almost 2,000 of these cases were found. According to a special report by the American Medical Billing Association (AMBA), “Medicaid payments to banned providers could easily reach into the hundreds of millions of dollars.” Those hundreds of millions of dollars being lost across dozens of states should instead be going into the expansion of Medicaid promised by the ACA.

While the act saw these problems and asked for a data sharing solution from the Centers for Medicare and Medicaid Services (CMS), the system adopted has demonstrated the flaws already mentioned above (missing and false data), in addition to having loose language with multiple interpretations. On top of those flaws, state and federal requirements for reporting Medicare fraud are not always the same.

In fact, one discrepancy established by the AMBA is that “under federal law, states aren’t required to terminate all revoked providers.” A lack of termination is a direct provocation of the problems denoted above. In general, fraudulent doctors and billers are being allowed to maintain work and essentially takes money from those who should truly claim it.

Whether or not your practice has suffered from dealings with a fraudulent party, it’s important to take precautions for the future of the practice and the medical community. Obtain background checks for all incoming medical staff through the CMS data sharing system. Likewise, review your practice’s procedures for reporting Medicare fraud. Take the necessary steps to both terminate and revoke the guilty party. If your practice could use guidance in reporting Medicare fraud, new ICD-10 coding, or general efficiency, consider practice management consultation with Billing Advantage.