Political pressure impedes some nursing home overbilling investigations, WSJ claims

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Pressure from politicians sometimes undermines efforts to stop overbilling by keeping Medicare and Medicaid payments flowing to nursing homes under investigation, The Wall Street Journal claimed in an article published Thursday.

A case involving 33 Florida nursing homes illustrates the issue, wrote reporters Christopher S. Stewart and Christopher Weaver. Medicare auditors began investigating the facilities in 2011, and became concerned about potential overbilling for therapy services. The auditors implemented pre-payment reviews, which block reimbursements pending further investigation.

At the behest of the Florida Health Care Association, Florida Gov. Rick Scott (R) contacted Centers for Medicare & Medicaid Services Administrator Marilyn Tavenner about the situation, according to the WSJ. Scott and Tavenner previously had worked together as executives at a healthcare company. After their discussion, payments were restored to the facilities.

Law enforcement has been contacted regarding seven of the nursing homes and efforts to recoup payments from 30 are underway, CMS told the reporters. None of the facilities was under pre-payment review as of January 2014.

The need to prevent inappropriate payments must be weighed against the possibility that withholding reimbursements could compromise patient care, Tavenner explained in a written statement to the newspaper. And she noted that being responsive to elected officials is not out of line; these officials are one of the “constituencies that CMS serves,” she wrote, along with beneficiaries and professional organizations.

Scott is not the only politician who has pressured Tavenner's agency to keep money flowing to providers, according to the article.

“More than a dozen former investigators and CMS officials said in interviews that they faced questions from members of Congress about policy changes or punitive action affecting providers or individual doctors,” Stewart and Weaver wrote.

Politicians want to keep large employers like nursing homes and hospitals operating in their districts, and sizeable campaign contributions from providers might further incentivize them to intervene in these situations, the article suggests.

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