NCJ Number
67077
Date Published
1979
Length
244 pages
Annotation
TESTIMONY ON FACTORS FACILITATING FRAUD AND ABUSE IN INTERMEDIARIES' PROCESSING OF MEDICARE CLAIMS IN THE TAMPA, FLA., AREA IS PRESENTED BEFORE THE HOUSE SUBCOMMITTEE ON OVERSIGHT.
Abstract
THE GENERAL PURPOSE OF THE HEARING, CONDUCTED IN TAMPA, FLA., ON DECEMBER 13, 1978, WAS DETERMINE WHETHER THE GOVERNMENT WAS DOING AN ADEQUATE JOB IN DETECTING AND ELIMINATING FRAUD AND ABUSE IN THE MEDICARE PROGRAM. SPECIFICALLY, THE SUBCOMMITTEE WANTED TO KNOW ABOUT THE PERFORMANCE OF THE INTERMEDIARIES--THE LINKS BETWEEN PROVIDERS (HOSPITALS, NURSING HOMES, AND DOCTORS, ETC.) AND THE FEDERAL GOVERNMENT. THE INTERMEDIARIES ARE GENERALLY PRIVATE INSURANCE COMPANIES WHO ADMINISTER THE MEDICARE PROGRAM FOR THE FEDERAL GOVERNMENT ON A REASONABLE COST BASIS. THE INTERMEDIARIES ALSO DO POSTAUDITING OF COST REPORTS. THE HEALTH CARE FINANCING ADMINISTRATION (HCFA) WITHIN THE DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE MONITORS THE PERFORMANCE OF THE INTERMEDIARIES. THIS MONITORING WAS ALSO REVIEWED IN THE HEARING TESTIMONY. TESTIMONY WAS HEARD FROM TWO LAWYERS WITH EXPERIENCE IN THE MEDICARE FRAUD PROGRAM, A REPRESENTATIVE OF THE UNITED STATES ATTORNEY'S OFFICE IN TAMPA, REPRESENTATIVES FROM TWO OF FLORIDA'S LARGEST INTERMEDIARIES, AND A REPRESENTATIVE FROM HCFA. THE NATURE OF ALLEGED FRAUD AND ABUSE BY THE PROVIDERS WAS DISCUSSED, AND INTERMEDIARIES' PROCEDURES FOR PROCESSING CLAIMS WHICH HAMPER THE DETECTION OF PROVIDER FRAUD AND ABUSE ARE IDENTIFIED. INADEQUACIES IN THE INVESTIGATION AND PROSECUTION OF MEDICARE FRAUD WERE ALSO CONSIDERED. SOME SUGGESTIONS FOR REMEDYING INADEQUACIES WERE OFFERED BY THE WITNESSES. SAMPLES OF FORMS USED IN THE INTERMEDIARIES' PROCESSING OF CLAIMS ARE PROVIDED. (RCB)