Grassley: Check for Fraud before Paying Claims

WASHINGTON — Under current law, Medicare is required to
pay claims in 30 days. But with limited resources, CMS only reviews
a fraction of the claims it receives — about 3 percent,
according to Acting Administrator Charlene Frizzera — before
payment.

Sen. Charles Grassley, R-Iowa, believes something must change,
and he introduced a bill Nov. 16 designed to give Health and Human
Services more time to pay up if fraud is suspected.

Grassley’s “Fighting Medicare Payment Fraud Act of 2009” would
empower the HHS Secretary to extend the time period in which
payments must be made to providers and suppliers (home care and
otherwise), if fraud, waste or abuse seems likely. A press release from Grassley outlined provisions
that would mandate more detailed reviews of the Medicare claims in
question to make sure they are supposed to be paid.

“Because of this prompt payment rule, the government puts itself
in a position of having to pay and chase Medicare fraud, instead of
working to prevent it in the first place,” said Grassley. “That
doesn’t make any sense, and it’s no way to manage Medicare’s
resources.”

Grassley’s release specifically referenced a recent CBS “60 Minutes”
story that reported on “a medical supply company that billed
Medicare $2 million in July, despite being located in an empty
building and having apparently no staff.”

Conservative estimates routinely peg the cost of Medicare fraud
at a whopping $60 billion annually, with expenditures predicted to
go up at an average annual rate of 7.1 percent from 2009 to 2018.
“As Medicare spending continues to skyrocket, everything possible
must be done to protect Medicare dollars from being lost to fraud,
waste and abuse,” Grassley said in the release. “This common-sense
change would go a long way in helping to make sure Medicare dollars
are going to bona fide providers, instead of fraudulent providers
who scam the system.”

Specifically, Grassley’s legislation proposes an extension of up
to one year to pay claims for categories of providers or suppliers
in a particular geographic area, or individual providers when there
is a likelihood of fraud, waste or abuse. For individual providers
or suppliers, the Secretary would be required to take whatever time
is necessary to engage in more in-depth reviews to determine if the
claims should be paid in the first place.

In addition, the Office of Inspector General would be required
to recommend categories of providers where additional scrutiny is
needed before payments are made under the prompt payment rule. To
make sure there is action, the HHS Secretary would be required to
provide a response to the recommendations.

“We’ve seen in reports revealed this fall how the Department of
Health and Human Services turned a blind eye for many years to
alerts from the Inspector General about Medicare fraud,” lamented
Grassley. “This provision in the bill is intended to make sure the
Department of Health and Human Services can’t get away with
ignoring those kinds of alarms.”

Although HME providers are currently fighting numerous issues
— among them the reprise of competitive bidding — Tyler
Wilson, president and CEO of the American Association for Homecare,
has repeatedly said concerns about fraud and abuse must “pillar all
other conversations.” The association continues to push its
13-point
anti-fraud plan, which proposes mandatory site inspections for
all new providers in addition to a six-month trial period.