FRAUD CONTROL UNITS GEAR UP TO DETECT ILLEGAL BILLINGS AND PROSECUTE OFFENDERS

• NCJ Number: 53651
• Journal: Forum Volume: 2 Issue: 4 Dated: (APRIL 1978) Pages: 2-5
• Author(s): A SLAYTON
• Date Published: 1978
• Length: 4 pages
• Corporate Author: US Dept of Health, Education, and Welfare
• Sale Source: National Institute of Justice/
• Language: English
• Country: United States of America

Annotation

STRATEGIES USED BY THE DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE HEALTH CARE FINANCING ADMINISTRATION (HCFA) TO INVESTIGATE AND CONTROL MEDICAID AND MEDICARE PROGRAM ABUSE AND FRAUD ARE REVIEWED.

Abstract

AUTHORITIES ESTIMATE THAT HEALTH CARE PROVIDER FRAUD AND ABUSE IN MEDICAID AND MEDICARE PROGRAMS PRODUCE A LOSS OF $4.5 BILLION ANNUALLY IN FEDERAL FUNDS. BEFORE THE MEDICARE-MEDICAID ANTI-FRAUD AMENDMENTS WERE PASSED IN 1977, STATES' MEDICAID AGENCIES WERE RESPONSIBLE FOR DETECTING, INVESTIGATING, AND DEVELOPING SUSPECTED CASES OF FRAUD, AND GREAT VARIATIONS IN STATES' ABILITIES TO CONTROL FRAUD DEVELOPED. THE AMENDMENT ESTABLISHED THE OFFICE OF PROGRAM INTEGRITY WITHIN HCFA TO INVESTIGATE THIS PROBLEM AND COORDINATE STATE ACTIVITY. IN 1978, HCFA HAD 280 PROGRAM INTEGRITY SPECIALISTS AROUND THE COUNTRY, 65 PROFESSIONAL INVESTIGATORS, AND 70 ADDITIONAL AUTHORIZED INVESTIGATORS. THESE INVESTIGATORS ARE TRAINED IN GENERAL MEDICAID AND MEDICARE PROGRAM REGULATIONS, GIVEN AN INTRODUCTORY COURSE IN CRIMINAL LAW, WITH EMPHASIS ON STATUTES PERTAINING TO MAIL FRAUD, FALSE STATEMENTS AND CLAIMS, AND EMBEZZLEMENT AND THEFT, AND INSTRUCTED IN EVIDENCE GATHERING. STATES HAVE INDEPENDENT FRAUD CONTROL UNITS THAT DERIVE 90 PERCENT OF THEIR FUNDING FROM HCFA. THE UNITS ARE SEPARATE FROM MEDICAID AGENCIES, AND LOCATED WITHIN OFFICES OF THE STATE ATTORNEY GENERAL OR A STATEWIDE PROSECUTION AUTHORITY. THE UNITS HAVE A COMBINATION OF INVESTIGATORS, ATTORNEYS, AUDITORS, AND PROFESSIONALS KNOWLEDGEABLE IN MEDICINE, PHARMACY, AND MEDICAID LAWS. THE UNITS HAVE UNIFORM REPORTING REQUIREMENTS WHICH PRODUCE A CONTINUOUS FLOW OF INFORMATION FOR CONSTRUCTING A NATIONAL PICTURE OF THE FRAUD PROBLEM. SEVENTEEN STATES SUBSCRIBE TO THE INSTITUTE FOR MEDICAID MANAGEMENT CLAIMS PROCESSING AND INFORMATION RETRIEVAL SYSTEM DESIGNED TO ELIMINATE PAYMENT ERRORS AND SPOT IMPROPER PATTERNS OF BILLINGS. THE HEALTH, EDUCATION AND WELFARE MEDICAID EXCEPTION REPORTING SYSTEM, WHICH IDENTIFIES CASES FOR INVESTIGATION, WILL EVENTUALLY BE INSTALLED IN ALL STATE FRAUD UNITS.