Waste of funds and abuse of the health care programs cost taxpayers billions of dollars

From the Health and Human Services (HHS) web site:

Waste of funds and abuse of the health care programs also cost taxpayers billions of dollars. In fiscal year (FY) 2009, the Centers for Medicare & Medicaid Services (CMS) estimated that overall, 7.8 percent of the Medicare fee-for-service claims it paid did not meet program requirements. Although these improper payments do not necessarily involve fraud, the claims should not have been paid. For our part, Office of Inspector General (OIG) reviews claims for specific services, based on our assessments of risk, to identify improper payments.

OIG has Five-Principle Strategies for Combating Health Care Fraud, Waste, and Abuse

Combating health care fraud requires a comprehensive strategy of prevention, detection, and enforcement. OIG has been engaged in the fight against health care fraud, waste, and abuse for more than 30 years. Based on this experience and our extensive body of work, we have identified five principles of an effective health care integrity strategy.

1.      Enrollment:  Scrutinize individuals and entities that want to participate as providers and suppliers prior to their enrollment or re-enrollment in the health care programs.

2.       Payment:  Establish payment methodologies that are reasonable and responsive to changes in the marketplace and medical practice.

3.      Compliance:  Assist health care providers and suppliers in adopting practices that promote compliance with program requirements.

4.      Oversight:  Vigilantly monitor the programs for evidence of fraud, waste, and abuse.

5.      Response:  Respond swiftly to detected fraud, impose sufficient punishment to deter others, and promptly remedy program vulnerabilities.

OIG uses these five principles in our strategic work planning to assist in focusing our audit, evaluation, investigative, enforcement, and compliance efforts most effectively. These broad principles also underlie the specific recommendations that OIG makes to HHS and Congress.

Hark and Moody, Inc. believes that these Five-Principles that OIG uses in their strategic work plan would also help us in the fight against Medicare Fraud, Waste, and Abuse in the following ways:

Enrollment:  Receive enough information to make sure that the individual/small business is Eligible to enroll into a health care program.

Payment:  Make sure the procedure(s) are medically necessary before billing for payment.

Compliance:  Make sure that the providers/suppliers are in compliant with the ever changing laws and regulations.

Oversight:  Monitor the high risked areas to make sure they are compliant also.

Response:  Turn over any expected Fraud, Waste, and Abuse allegations to the proper authorities.

Creating a new Competitive Marketplace: Affordable Insurance Exchanges

In 2014, individuals and employees of small businesses will have access to affordable coverage through a new competitive private health insurance market—State-based Affordable Insurance Exchanges. Affordable Insurance Exchanges will provide individuals and small businesses with a “one-stop shop” to find and compare affordable, quality private health insurance options. Exchanges will bring new transparency to the market so that Americans will be able to compare plans based on price and quality. By increasing competition between insurance companies and allowing individuals and small businesses to band together to purchase insurance, Exchanges will help lower costs.

  

The Affordable Care Act introduces a series of consumer choices and insurance competition through health benefit exchanges. The Exchange is a state-based marketplace that will accept applications and will determine eligibility. It will also participate and enroll applicants into affordable health insurance affordability programs. Each state is required to establish an Exchange that will address the needs of individuals and small businesses. Section 1311 of the Affordability Care Act directs CMS to establish and operate Exchanges within states that do not elect to establish an Exchange before January 1, 2014. Each state can tailor the Exchange to meet its own needs. The first open enrollment will begin October 1, 2013

CMS shall design an approach to be in compliance with the Affordable Care Act along with its amendments. CMS will work with contractors to ensure that the FEPS has the necessary information to make eligibility determinations, along with providing other support services as needed.

Hark and Moody, Inc as a contractor or subcontractor, would like to join CMS in the endeavor to design an approach to be in compliance with the Affordable Care Act. Hark and Moody, Inc. would like to be part of the Eligibility and Enrollment Management team that is overlooking the Exchange and help support the states in this step.

CMS Program Integrity Manual

In the Center for Medicare & Medicaid Services (CMS) manuals publication 100-08 titled Medicare Program Integrity Manual section 4.1 states as follows:

The Program Integrity Manual (PIM) reflects the principle, values, and priorities of the Medicare Integrity Program (MIP). The primary principle of Program Integrity (PI) is to pay claims correctly. In order to meet this goal, program safeguard contractors (PSCs), Zone Program Integrity Contractors (ZPICs), affiliated contractors (ACs), and Medicare administrators contractors (MACs) must ensure that they pay the right amount for covered and correctly coded services rendered to eligible beneficiaries by legitimate providers. The CMS follows four parallel strategies in meeting this goal:  1) preventing fraud through effective enrollment and through education of providers and beneficiaries, 2) early detection, 3) close coordination with partners, including PSCs, ZPICs, ACs, MACs, and law enforcement agencies, and 4) fair and firm enforcement policies.

Hark and Moody, Inc.'s Statement

Hark and Moody, Inc. (Hark and Moody) has a well-rounded Compliance Program that reflects the Recovery Audit's commitment to the compliance of the laws and regulations of the Recovery Audit Program. Hark and Moody's compliance program is also consistent with the Healthcare Insurance Portability and Accountability Act of 1996 (HIPAA), Department of Health and Human Services (HHS) Office of Inspector General's (OIG) Compliance Program Guidance for Third-Party Medical Billing Companies. The goal of Hark and Moody's Compliance Program is to maintain an environment that promotes the prevention, the detection, and resolution of potential violations of law and/or Company Policy.

Hark and Moody's Compliance Program involves regular assessments, audits, and adjustments to ensure that the Program Integrity and Company Integrity response to the Company's business and associated compliance risks. Hark and Moody is fully committed to making sure the company complies with the Medicare Integrity Program by following the guidelines set-forth in the Medicare Program Integrity Manual.

Health Care Fraud Prevention and Enforcement Efforts Result in Record-Breaking Recoveries Totaling Nearly $4.1 Billion

Largest Sum Ever Recovered in Single Year

WASHINGTON –Attorney General Eric Holder and Department of Health and Human Services (HHS) Secretary Kathleen Sebelius today released a new report showing that the government’s health care fraud prevention and enforcement efforts recovered nearly $4.1 billion in taxpayer dollars in Fiscal Year (FY) 2011.  This is the highest annual amount ever recovered from individuals and companies who attempted to defraud seniors and taxpayers or who sought payments to which they were not entitled. 

These findings, released today, in the annual Health Care Fraud and Abuse Control Program (HCFAC) report, are a result of President Obama making the elimination of fraud, waste and abuse a top priority in his administration.  The success of this joint Department of Justice and HHS effort would not have been possible without the Health Care Fraud Prevention & Enforcement Action Team (HEAT), created in 2009 to prevent fraud, waste and abuse in the Medicare and Medicaid programs, and to crack down on the fraud perpetrators who are abusing the system and costing American taxpayers billions of dollars.  These efforts to reduce fraud will continue to improve with the new tools and resources provided by the Affordable Care Act.

“This report reflects unprecedented successes by the Departments of Justice and Health and Human Services in aggressively preventing and combating health care fraud, safeguarding precious taxpayer dollars and ensuring the strength of our essential health care programs,” said Attorney General Holder.  “We can all be proud of what's been achieved in the last fiscal year by the Department’s prosecutors, analysts and investigators – and by our partners at HHS.  These efforts reflect a strong, ongoing commitment to fiscal accountability and to helping the American people at a time when budgets are tight.”

“Fighting fraud is one of our top priorities and we have recovered an unprecedented number of taxpayer dollars,” said Secretary Sebelius.  “Our efforts strengthen the integrity of our health care programs, and meet the President’s call for a return to American values that ensure everyone gets a fair shot, everyone does their fair share, and everyone plays by the same rules.”

Approximately $4.1 billion stolen or otherwise improperly obtained from federal health care programs was recovered and returned to the Medicare Trust Funds, the Treasury and others in FY 2011.  This is an unprecedented achievement for HCFAC, a joint effort of the two departments to coordinate federal, state and local law enforcement activities to fight health care fraud and abuse. 

Hark and Moody, Inc., as a U.S. Procurement Contractor is committed in helping with preventing, detecting, and recovery of improper payments due to fraud, waste, and abuse of the health care system. Hark and Moody, Inc. has been vigorously training, implementing, and taking the necessary steps to get involved in the fight against the nation's health care fraud, waste, and abuse problems.  

CMS TAKES STEPS TO REDUCE IMPROPER PAYMENTS AND SAVE MONEY FOR MEDICARE

The Centers for Medicare & Medicaid Services (CMS) today announced that it is moving forward with a new initiative to reduce errors, and save money for Medicare. New audits of Medicare Advantage contracts will reduce the payment error rate for the Medicare Advantage program and will recover an estimated $370 million in overpayments for the first audit year.  This estimate is a projection, and actual recovery amounts may vary depending on audit findings.

 “Fighting fraud, improving payment accuracy, and saving money for Medicare is one of our top priorities,” said CMS Acting Administrator Marilyn Tavenner.  “CMS will use a new method of auditing Medicare Advantage plans that improves program integrity and reflects public input.” CMS received more than 500 comments on its draft methodology.

CMS is required to adjust payments to MA organizations based on the health status of their plan enrollees.  To receive risk-adjusted payments, MA organizations submit data to CMS. The Improper Payments Elimination and Recovery Act (IPERA) of 2010 requires CMS to annually audit these data.  From FY 2010 to FY 2011, CMS successfully reduced the payment error rate for the MA program by three percentage points (from 14.1 to 11 percent).

The new initiative launched today will further improve these audits.  The final audit methodology announced today for the Risk Adjustment Data Validation (RADV) program aims to further reduce the MA error rate.

This article was posted on the CMS website earlier this year. As a government procurement contractor, Hark and Moody, Inc. is committed to helping CMS and others in fighting Medicare fraud, waste, and abuse. Hark and Moody, Inc. has began the steps that is required to join in  the fight against fraud, waste, and abuse of the health care system.  

Recovery Auditing

Need help with health care billing  by CMS and HHS? We Here at Hark and Moody make it easy.

Call  1-888-332-7410 ext 4700 or visit us at http://harkandmoody.com/

Solutions

Hark and Moody Inc is able to track missed payments, recoup funds paid in error, and assist in establishing preventative measures to reduce the likelihood of future Issues.

The use of modern technology is integral to our methods, and the experience of our staff is also a key tool in identifying the errors.

All data that we handle is kept completely secure and confidential.  We are able to carry out both automated and manual analysis of the data as required, and thoroughly investigate every case to discover where the errors have been made in order to make the required corrections.

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http://www.harkandmoody.com/