Medicare, Medicaid stay on 'high risk' list

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Medicare overpayment issues and poor Medicaid data are two of many problems keeping long-term care's biggest payers on a government watch list of “high-risk” programs, according to a new General Accountability Office report.

Improvement will come only through much improved management and oversight, the GAO said. For Medicare, for example, that means improvements in beneficiary use of services and quality of care, and physician incentive payments and profiling. According to GAO researchers, Medicare reported an estimated $60 billion in improper payments in 2014.

In its 404-page “High Risk Series” report to Congress, released Wednesday, the watchdog agency notes that both programs remain “highly vulnerable to fraud, waste and abuse.” Report authors outlined a series of recommendations intended to get the programs off the list in the coming years. Medicare, long-term care's second biggest source of income, has been on the risk report every year since the GAO began publishing it in 1990; Medicaid, LTC's biggest payer, has since 2003.

Medicare payment rates remain unacceptably high, while the Medicaid program continues to be plagued by a dearth of accurate, reliable and timely data at the federal level, GAO investigators found. Exacerbating the problems with Medicaid is its booming enrollment growth fueled by broader eligibility criteria under the Affordable Care Act. Medicaid payment improprieties rose to 6.7% last year, compared to 5.8% in 2013.

The GAO report didn't skimp on praising the positive steps the Department of Health and Human Services and the Centers for Medicare & Medicaid Services have taken the past two years to curb payment issues and fraud. They include better Medicare audit contractor monitoring and more effective and efficient agency inspections, strengthening provider and supplier enrollment rules, and improving the fee-for-service pre- and post-payment claims review processes.

Among the GAO's more specific recommendations are calls for: More frequent dissemination of physician performance reports; closer scrutiny of long-term care hospitals and Medicare contractors treating end-stage renal disease; and better diagnostic coding practices regarding differences between Medicare Advantage and Medicare fee-for-service.