Feds fight uphill battle in fraud crackdown

Law enforcement officials estimate that fraud drives up to 10 percent of Medicare's annual spending, but recovering that money and preventing more losses can be a David-and-Goliath fight, according to reports in the New York Times and the Wall Street Journal. "[E]ven with the fancy computers and expert teams, the government is not close to defeating the fraudsters," The Times noted. 

Some sobering facts support this.  

Of roughly $60 billion lost to fraud and overbilling annually, the federal government recouped only about $4.3 billion last year, The Times reported. "Usually the money gets away," said special agent-in-charge Glenn Ferry, who oversees the Office of Inspector General's strike force in Los Angeles, to the WSJ. "As soon as it hits an account, it disappears."

Requirements to process Medicare claims within 30 days of receipt can put fraud investigators "behind the eight ball," the WSJ noted. Tracking billings is difficult since about 4.5 billion Medicare claims adjudicate daily.

And whether Medicare's new fraud prevention system has been successful is unclear. The Office of Investigations verified only $54 million in savings due to the system though others credit it for identifying $211 million in inappropriate claims, The Times reported.

Another challenge is keeping bad actors out of Medicare. Though criminal conviction or medical license loss can prompt exclusion from participation in federal programs, providers can appeal exclusions and be reinstated, the WSJ reported.     

Moreover, charges of mismanagement and conflicts of interest dog the government's anti-fraud contractors. Lines of authority and responsibilities among them aren't clearly defined, The Times noted, and contractors have refused to share information. Though recovery audit contractors returned $8 billion to Medicare since 2009, hospital resistance to them and an overwhelmed provider appeals process have taken the teeth out of recovery efforts.  

Questionable administrative decisions can also hinder anti-fraud efforts. The government shut down a fraud reporting hotline in Florida, for example, even though tips on that line led to more than 1,000 investigations and highlighted of millions in dubious payments, The Times reported.     

For more:
- here's the WSJ article (subscription required)
- read the New York Times article

Feds prioritize beneficiary hearings, postpone provider appeals