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Originally Posted by
Lanie
You either want government involvement in our healthcare or you don't. Which is it?
People that paid into Medicare and served in the military have already had gov't in healthcare. Just like those that work for the gov't. Don't forget all those on disability and medicaid. The business community is often forced to eat the extra costs.
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President Obama made a commitment to reduce Medicare fraud 50% by 2012. One tool to meet this goal is provisions in the Affordable Care Act that provide an additional $350 million over 10 years to help fight fraud. Part of this fight against fraud includes the creation of an integrated data repository combining data from CMS with other federal programs (e.g., Medicaid, Veterans Administration, Department of Defense, Indian Health Service, etc). The Act also includes agreements that make it easier for the government to share data, identify criminals, and prevent fraud. It also contains stricter rules for providers and suppliers, requiring them to establish detailed plans about how they will follow the rules and prevent fraud. New stronger civil and monetary penalties will also be imposed on offenders.
The President is trying to pay for Obamacare with increased fines for doctors and pharmacists. New expensive record keeping systems will have to be put in place, on top of the 350M the gov't will be spending.
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Expect to see more audits overall, but you'll also see more groups auditing...plan sponsors, PBMs, CMS, states, and contract "bounty hunters" working on behalf of the government. These are contracted entities that have the power to audit and receive a percentage of the money they recover. You'll also see audits that extrapolate findings over your entire business and over a couple of years. For example, if auditors identify 2 or 3 claims submitted incorrectly, they'll calculate how much of your business is with a particular government program, calculate the % error rate, multiply it by 2 years, and seek that amount in repayment.
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Keep in mind that the government expects to allay at least part of the cost of health care reform through their fraud fighting efforts, so they'll be looking for ways to successfully collect fraud money.
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It is important to understand that the person perpetrating the fraud doesn't need to have known that the information they provided was false
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New providers and suppliers will be assessed for their level of fraud risk and could be subject to fingerprinting, site visits, and criminal background checks before they are allowed to bill. Payment to individuals or organizations can be withheld if a credible allegation of fraud is made and an investigation is pending.
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The False Claims Act contains a whistle-blowers or qui tam provision that allows citizens with evidence of fraud against the government to sue on behalf of the government. They are eligible to receive a portion of the money recovered, usually between 15% and 25%. The rest of the money goes to the government. Whistle-blowers can be anyone...current or ex-employees or even competitors.
The cost of malpractice insurance is going to be huge.
These are just some of the new rules, part of which I posted above:
•Department of Health and Human Services. Centers for Medicare and Medicaid Services. Prescription Drug Benefit Manual Chapter 9 - Part D program to Control Fraud, Waste and Abuse. Updated April 25, 2006. http://www.cms.gov/PrescriptionDrugC...apter9_FWA.pdf (Accessed December 1, 2011).
•Department of Health and Human Services. Centers for Medicare and Medicaid Services. Medicare Learning Network. Medicare Fraud and Abuse. February 2010. http://www.cms.gov/MLNProducts/downl..._and_Abuse.pdf (Accessed December 1, 2011).
•Social Security Act. Exclusion of certain individuals and entities from participation in Medicare and State health care programs. Title XI, Section 1128A. www.ssa.gov/OP_Home/ssact/title11/1128.htm (Accessed December 1, 2011).
•Social Security Act. Civil monetary penalties. 42 U.S.C. §1320a-7b(a). www.ssa.gov/OP_Home/ssact/title11/1128A.htm (Accessed December 1, 2011).
•Department of Health and Human Services. Centers for Medicare and Medicaid Services. Federal Register. 42 CFR Parts 400, 403, 411, 417, and 423
•Medicare Program; Medicare Prescription Drug Benefit; Final Rule. January 28, 2005. http://edocket.access.gpo.gov/2005/pdf/05-1321.pdf (Accessed December 1, 2011).
•Department of Health and Human Services. Centers for Medicare and Medicaid Services. Federal Register. 42 CFR Parts 422 and 423 Medicare Program; Revisions to the Medicare Advantage and Part D Prescription Drug Contract Determinations, Appeals, and Intermediate Sanctions Processes; Final Rule. December 5, 2007. http://www.cms.gov/quarterlyprovider.../cms4124fc.pdf (Accessed December 1, 2011).
•Department of Health and Human Services. Centers for Medicare and Medicaid Services. CMS Manual System. Pub. 100-16 Medicare Managed Care. August 7, 2009. http://www.cms.gov/ManagedCareMarket...ads/R91MCM.pdf (Accessed December 1, 2011).
•Department of Health and Human Services. Office of Inspector General. Fraud Prevention & Detection. www.oig.hhs.gov/fraud.asp (Accessed December 1, 2011).
•Anon. Affordable Care Act Update: Implementing Medicare Cost Savings. www.mmapinc.org/pdfs/ACA-
Update-Implementing-Medicare-Costs-Savings.pdf (Accessed December 1, 2011).
•Department of Health and Human Services. Centers for Medicare and Medicaid Services. Federal Register. 42 CFR Parts 417, 422, 423 and 480 Medicare Program; Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs; Final Rule. April 15, 2010. http://edocket.access.gpo.gov/2010/pdf/2010-7966.pdf (Accessed December 1, 2011).
•Department of Health and Human Services. Office of Inspector General. Medicare Prescription Drug Sponsors' Training to Prevent Fraud, Waste, and Abuse. July 2011. http://oig.hhs.gov/oei/reports/oei-01-
10-00060.pdf (Accessed December 1, 2011).
•United States Government Accountability Office. Report to Congressional Requesters. Medicare Part D: Instances of questionable access to prescription drugs. www.gao.gov/products/GAO-12-104T (Accessed December 1, 2011).
