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OIG cites fraud, other issues in Medicaid home healthcare


The Office of Inspector General of the U.S. Department of Health & Human Services has reported that there are continuing serious compliance, payment and fraud issues in the Medicaid home healthcare program for disabled and elderly people.

The OIG said that since 2012, it has investigated more than 200 cases involving fraud, patient harm and neglect in the  program.

Among OIG’s observations:

“From OIG’s experience, PCS {personal care service} providers, including agencies and individual attendants, have commonly used aggressive tactics when recruiting Medicaid beneficiaries to participate in PCS fraud schemes. Likewise, OIG has observed Medicaid beneficiaries voluntarily participating in such schemes,” the  office wrote.

The OIG  asked that CMS improve monitoring of PCS programs, including  establishing minimum federal qualifications and screening standards for PCS workers, including background checks, and requiring that PCS claims list the dates of service and the names of PCS people who provided services.

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Many banned Medicaid providers work in other states


A federal auditor reports that undreds of medical providers banned from a Medicaid program in one state have been able to participate in another state’s program despite regulations designed to stop them. This leaves Medicaid programs more open to fraud, waste and other abuse.

Reuters reported that investigators, working for  the U.S. Department of Health and Human Services Office of the Inspector General (OIG), “also found that about half of the states were unable to terminate providers enrolled in privately run Medicaid managed care programs. Some refuse to terminate providers still licensed by a medical board, {investigators} found.”

“If a provider has been terminated by a state, that is a red flag, because it would indicate there was a problem either in billing or the way they handle patients,” said Deborah Cosimo, team leader for the report. “Do states really want to trust beneficiary care to someone who has problems like that?”

“The latest report may underestimate the number of providers who continue to participate in Medicaid after termination and the amount they were paid due to poor record keeping by the states, the auditor wrote.”



“Circularity concerns’ about ASC reimbursements



Modern Healthcare reports that as the crackdown on high hospital pricing continues (including sky-high hospital “facilities fees”), the Office of the Inspector General of the U.S. Department of Health and Human Services “is using a congressionally mandated report to repeat its call for Medicare to pay hospitals the same as it pays ambulatory surgery centers (ASC’s) for low-risk outpatient procedures. ”

The policy change could save  taxpayers and Medicare patients $15 billion over five years, the OIG estimates, but would require legislation letting the Centers for Medicare &  Medicaid Services cut the rates for low-risk surgeries “without having to increase other payment rates to make the policy change budget-neutral as required by law.”
“The CMS also said the idea ‘may raise circularity concerns’ because ASC rates are based on a conversion factor from the outpatient prospective payment system for hospitals. Lowering those outpatient rates, that is, could affect the surgical center rates and create a kind of downward spiral.
Lowering those outpatient rates, that is, could affect the surgical center rates and create a kind of downward spiral.”
The CMS said that the Inspector General’s report didn’t offer clinical criteria “to distinguish which patients could be treated in ASCs rather than hospital outpatient settings.”

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