The tagline used to market awareness about Medicare is “As American As Apple Pie”. When you consider the grave importance of this federal health insurance program, it would be difficult to argue its value to the lives of all Americans. With that being said, it is with much disappointment that we’ve learned that Medicare continues to be taken advantage of. Sadly, it would appear that fraudulent healthcare claims are every bit as popular as apple pie in this great nation of ours.

As reported by Lisa Rein in the Washington Post earlier this month, Medicare has paid out a whopping $14.1 billion in improper claims within the span of one year. Private health insurance companies are reportedly misusing the Medicare Advantage private plans that offer assistance for care to the elderly among others in need. She notes that the Government Accountability Office is finding it difficult to protect the plans against fraud, waste and abuse.

The GAO report lists both fraud and unintentional mistakes as the reasons that billions of dollars have been incorrectly paid out. Safeguarding the program from such irregularities will be an important step in protect taxpayers from having their money mismanaged in the future. As for right now, however, Rein intimates that Medicare is enduring scamming with no end in sight. But why is the fraud so hard to detect?

“The overcharges come from a poorly run anti-fraud system administered by the Centers for Medicaid and Medicare Services, which pay out reimbursements to the private plans, GAO found,” reports Rein, “The agency has spent about $117 million on audits using a complex formula to pinpoint where the system is at risk of fraud. But so far it’s recovered only $14 million. In many cases, the private plans provide the government with ‘unsupported information’ about a patient’s health condition, conveying that it is worse than it really is.”

In fact, the vast majority of fraudulent claims were found to contain insufficient medical record documentation. Rein reveals that the GAO report found that nearly 75% of the improper payments doled out to private plans in 2013 resulted from claims that included patient diagnoses and medical records that did not align. As a result, Medicare must now be committed to reducing the number of improper payments made in future.

While providers are responsible for submitting claims that accurately reflect the documentation, it is incumbent upon the Medicare Advantage plans to provide audits, education and oversight to ensure that the claims data is accurate. In fact, the Office of the Inspector General continues to investigate this issue through their workplan (MA Organizations’ Compliance With Part C Requirements).

Rein reports that The Department of Health and Human Services, which is Medicare’s parent agency, is adamant about making a change. “HHS is strongly committed to program integrity in the Medicare Advantage program and takes seriously our responsibility to protect taxpayer dollars by identifying and correcting improper payments,” an agency representative is quoted as saying.

At Allegiant Experts, our team of clinical experts work for both sides on this issue. We assist Medicare Advantage Plans with remaining compliant with regulations by performing independent third party audits to ensure compliance with program integrity goals. We also support audits for government entities in an effort to locate and correct any plans that may be mismanaged. We are committed to promoting honesty, integrity and doing the right thing to ensure only the highest-quality healthcare services at the most reasonable prices.

Removing fraud, waste and abuse of healthcare claims from the system benefits everyone through cost reduction, decreased premiums and encouragement of quality care and documentation. Furthermore, taxpayer money should never be wasted. For more information on the clinical expert services provided by Allegiant Experts, please don’t hesitate to contact us at 407-217-5831.