Medicare outpatient community mental health centers located in states with little or no oversight accounted for at least 90% of more than $200 million in "questionable" billings in 2010, according to a report released Tuesday by HHS' Office of Inspector General, USA Today reports.
The centers are intended to cut Medicare spending by keeping beneficiaries out of inpatient hospital care, Latrice Rollins, an author of the report, said.
For the report, OIG investigators examined 195 centers nationwide in 2010 and identified a series of fraudulent billing cases at the centers. They focused on nine examples of questionable billing that originated from those cases and discovered $218 million in dubious billings for 25,000 Medicare patients.
The majority of questionable billings came from centers in Florida, Louisiana and Texas, which do not have licensing or certification requirements for mental health programs, according to the report. Rollins said the report "identified claims that show certain characteristics" suggesting potential fraud or questionable billing practices.
The report found that some centers billed Medicare for beneficiaries who lived as far as 4,000 miles away and submitted claims for beneficiaries who never were seen by physicians. In addition, investigators found that some centers billed Medicare for counseling services to Alzheimer's patients that were not beneficial and for patients who did not have physician referrals.
According to USA Today, the report recommends improved monitoring standards, enforcing physician certification of patients and better reviews of questionable billing. CMS already has issued a rule that would require conditions of participation for providers, USA Today reports. The rule is set to take effect in 2014 (Kennedy, USA Today, 8/21).
Medicare Anti-Fraud Teams Get Boost From Affordable Care Act, Other Legislation
The federal health reform law and other legislation will provide Medicare anti-fraud teams with sophisticated tools and funding to better identify individuals seeking to profit from the program, NPR's "Shots" reports.
Previous estimates show that as much as $65 billion of the $750 billion paid annually to more than 1.5 million Medicare providers is lost to fraud.
However, ACA and other legislation have been designed to equip federal officials with aggressive anti-fraud computer systems that can sift through millions of Medicare claims daily to identify outliers, according to "Shots."
In addition, Congress over the next 10 years is expected to distribute about $340 million in additional funding to government anti-fraud initiatives (Varney, "Shots," NPR, 8/21).