Miami-Dade County a hotspot for Medicare fraud

Evidence in a new Department of Health and Human Services report on outpatient therapy from the Office of the Inspector General confirms what many have long suspected: Miami-Dade County has earned the dubious distinction of being Ground Zero for Medicare fraud in the U.S.

Medicare spending per beneficiary on Dade County was three times the national average in 2009 ($3,459 vs. $1,078 nationally). And beneficiaries in the county received more than three times the number of services over the national average (158 vs 49) in 2009. Worse yet, Medicare dollars went disproportionately to pay for outpatient therapy for Miami-Dade residents; Medicare paid therapy providers in that area $83,867, eight times the national average ($10,131). Ouch.

What's more, Miami-Dade County was associated with at least three times the national levels for five "questionable billing characteristics" in Medicare outpatient therapy services. For example, Miami-Dade beneficiaries were three times more likely to receive outpatient therapy throughout the year than their peers nationally.

Among its recommendations, the OIG suggested that CMS review claims submitted by providers associated with high levels of questionable billing and in geographic areas with high use to ensure that they are legitimate--before paying anything. If CMS determines that fake claims have been submitted, it should take steps to suspend payments to providers and recover overpayments. CMS agreed with the OIG's recommendations.

Besides outpatient therapy services, Miami-Dade County, which has been a focus of efforts to fight Medicare fraud and abuse, has been associated with a higher risk for fake Medicare claims for infusion therapy services for patients with HIV/AIDS, home health services, inhalation drugs and ultrasound services.

Note to Miami-Dade-based providers of outpatient therapy services: The feds are on to you.

To learn more:
- read the OIG report

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