Following reports that more than 400 people had been charged with over $1.3 billion in fraudulent billings in the largest ever health care fraud enforcement action, U.S. Rep. Vern Buchanan (R-FL) led a congressional panel’s review on Wednesday of steps being taken to detect and curb fraud within Medicare programs.
Buchanan, the chairman of the House Ways and Means Subcommittee on Oversight, was joined by U.S. Reps. Jackie Walorski (R-IN), Carlos Curbelo (R-FL) and Patrick Meehan (R-PA) in probing the Centers for Medicare and Medicaid Services’ (CMS) efforts to fight fraud within Medicare during the subcommittee hearing. CMS oversees the fee-for-service Medicare program, the managed care Medicare Advantage program and Medicare Part D prescription drug program.
“Nearly 60 million Americans, including four million in my home state of Florida, rely on the Medicare program to provide care,” Buchanan said. “We have a responsibility to all of them, and to all taxpayers, to ensure that care is high quality, and that CMS is paying accurate and appropriate amounts to those providing the care. As it stands now, Centers for Medicare Services has not been in a position to ensure that this is the case.”
CMS reports that improper Medicare payments totaled $59.6 billion in 2015, amounting to approximately 10 percent of total Medicare spending.
Walorski noted that one prescriber in Indiana wrote an average of 24 opioid prescriptions each for 108 beneficiaries in a year, costing Medicare Part D $1.1 million.
“… The filters (CMS uses to identify fraud) aren’t working,” Walorski said, noting that the doctor who wrote those prescriptions wasn’t flagged. “Whatever was done prior to January 2017 is not working.”
Responding to a question from Walorski about what processes CMS has in place to flag and investigate suspicious prescribing practices, Acting CMS Director Jonathan Morse said the Medicare lock-in program, a provision of the Comprehensive Addiction and Recovery Act (CARA), is currently being implemented.
“Lock-in is something that’s been used very effectively by both state Medicaid programs, as well as by private payers, to be able to lock in a single beneficiary and a single prescriber,” Morse said. “So, essentially, it helps monitor that overutilization and it helps sort of prevent that abuse from happening.”
Still, Curbelo urged the Trump administration to do more to flag waste, fraud and abuse within the Medicare program. He read from a Miami Herald article about a doctor who pleaded guilty to conspiracy to commit health card fraud totaling $4.8 million.
“Now people in my community are sick and tired of having this reputation, and people in my community ask me, ‘How come Visa, American Express, MasterCard can prevent fraud, yet we are always reading about the Medicare fraud that is being chased in the newspaper?’” Curbelo said. “And I want to know today, from both of our witnesses, if there is any more authority that Congress can give CMS to remedy this situation?”
Curbelo added that the House Ways and Means Committee and Congress had to do “whatever it takes” to empower federal agencies to root out Medicare fraud.
“For taxpayers and for Medicare beneficiaries it’s very demoralizing to read — on a weekly basis in Miami — these articles about people running these schemes that have cost the taxpayers billions and billions of dollars and, by the way, threatened the solvency of Medicare, Social Security and many of our entitlement programs,” Curbelo added.
Furthermore, Meehan noted that only a small number of Medicare-related complaints are investigated.
“We are seeing not only a growth in concern about fraud, but the opioid epidemic – both on the front end, with over-prescription, but a growing concern about those who have entered into the treatment space … a recent subcommittee report from the Permanent Subcommittee on Investigations in the Senate found that only a small percentage of potential incidents of fraud and abuse in the Part D program were brought to the attention of [investigators] … ”
In 2015, Meehan noted, there were 8,900 total actionable complaints, but only about 7 percent were investigated.