Better anti-fraud efforts are not appeasing lawmakers

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Rep. Tim Murphy (R-PA)
Rep. Tim Murphy (R-PA)

Long-term care facilities and other Medicare providers increasingly have seen reimbursements influenced by the government's Fraud Prevention System, an official recently told a Congressional panel. The system prevented or recovered more than $210 million in improper payments during fiscal year 2013, more than doubling the amount from the system's first year, said Shantanu Agrawal, M.D., deputy administrator and director, Center for Program Integrity at the Centers for Medicare & Medicaid Services.

The Fraud Prevention System is designed to analyze billing patterns to flag potentially problematic payments. CMS has taken action against 938 providers and suppliers due to the system, Agrawal said in a June hearing of the House Energy & Commerce Committee's Oversight and Investigations subcommittee.

The improper payment rate increased from 8.5% to 10.7% between 2012 and 2013, but this does not necessarily signal surging criminal activity, Agrawal said. It could indicate providers are struggling to comply with more stringent rules related to payment, which have been implemented by the government to be “very strong on program integrity,” he said. His agency has launched an effort to educate providers “to make sure they are able to follow our rules … our documentation requirements,” he said. It's also working on strengthening disclosure requirements to prevent bad actors from starting a new company under a different name. 

Subcommittee chairman Rep. Tim Murphy (R-PA) criticized the agency.

“The bottom line for taxpayers” is that improper payments total more than the entire Pennsylvania state budget, he said. “So I hope you will improve that.” 

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