$1.2B recoveries expected with anti-fraud efforts

The government expects recoveries to total $1.2 billion, including $748 million from investigations and $483 million from audits in the first half of fiscal 2012, according to an Office of Inspector General report released Tuesday.

U.S. Health & Human Services Inspector General Daniel Levinson largely attributed the recoveries to data analytics, which allow federal agencies to conduct risk assessments and pinpoint areas for oversight, particularly from the data-driven Medicare Fraud Strike Force.

The Strike Force has had a banner year with record-breaking prosecutions of fraud, resulting in $50.9 million from investigative recoveries for the six-month period from October 2011 to March 2012. OIG's warehouse of integrated data from Medicare Parts A, B and D paint a comprehensive picture of beneficiaries' medical care histories and providers' billing patterns. OIG refers possible targets to the Centers for Medicare & Medicaid Services, which uses credible allegations to suspend payments under new authority from the Patient Protection and Affordable Care Act.

Although the recoveries have largely been made possible by data, the Inspector General noted "technology is not a silver bullet", according to the report. "Even with the best fraud prevention, technologies will be of little value if not effectively implemented and appropriately overseen," Levinson said.

Although CMS' Medicare Recovery Audit Program collected a record $588.4 million in overpayments in one quarter, according to a CMS report, the OIG noted CMS continues to have vulnerabilities, such as with claims coding and provider identifiers. Although CMS is aware of those vulnerabilities, it fails to have procedures to resolve them, OIG said in the report.

In addition to statute of limitations on overpayment collections, inadequate systems for documenting collections or detecting data entry errors leaves $332.1 million in Medicare overpayments on the table that CMS failed to collect on, OIG said last week.

To learn more:
- see the OIG report (.pdf)
- check out the CMS newsletter (.pdf)

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