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Wondering Where Your Taxpayer Dollars are Going?


Wondering where your taxpayer dollars are going?

Recently, in an article posted by the Office of Inspector General (OIG), scenarios are presented that illustrate a lack of quality-of-care for patients in senior nursing facilities. The article more specifically addresses how skilled nursing facilities, nursing homes that provide 24-hour assistance with day-to-day activities and rehabilitation services for patients, may not be the proper outlet for Medicare to be investing 32 billion dollars--as they did in 2012.  

Quality-of-Care Inefficiencies

Most of the problem lies in the lack of effort put into quality-care plans set forth by most SNF’s. These care plans are made to describe a patient’s medical, nursing, and psychosocial needs and describe how they will meet said needs. An alarming statistic from the article states that 37% of SNF stays in 2009 did not meet medicare requirements or the care was not in conjunction with the plan. Considering Medicare paid approx $4.5 billion for stays that had such care-plan problems, it is easy to see that funding is being used in improper and inefficient ways.  

Discharge Inefficiencies  

To show another piece (missing) from the puzzle, patients are issued discharge plans to safely transition them from SNF care to their new setting after their stay. These elements may include a summary of the patient’s stay, the patient’s status at discharge, or even the post-discharge plan of care. But still, for 31% of stays, the discharge plan was missing at least one of the required elements. This is another example of dollars being used inefficiently with Medicare paying roughly $1.9 billion for these stays that had deficient discharge plans.  

Medicaid and Medicare funding is based on taxpayer dollars. We found that tax dollars aren’t only being wasted on these SNF inefficiencies but also on unneccessary expenses that the government hasn’t fully thought through. According to Forbes.com the government spends tax dollars on:  

  1. On unnecessary printing costs.
  2. On an unused monkey house (and other structures).
  3. On fraudulent tax reimbursements to prisoners.
  4. On streetcar system that runs the same rout as the subway system below it.
  5. On an unprofitable shooting range
  6. On a three week conference for the FAA (Federal Aviation Administration
  7. Treadmills for shrimp
  8. On a study of World of Warcraft and other computer games
  9. On a U.S. Census commercial that appeared during the Super Bowl
  10. On a study about posting pictures online
  11. On new toilets for Denali National Park
  12. On a laundry-folding robot
  13. On a study about baby names  

It has become obvious that the Centers for Medicare and Medicaid Services have some serious issues with understanding where and why dollars are being spent. CMS could make changes to ensure that there will be less issues with overbilling and lacking in quality care for patients.

OIG Exclusion List & Drug Diversion Focus

oig exclusion list

According to the OIG, the illegal use and dispensing of prescription drugs is at epidemic proportions.  The OIG will continue to aggressively use data analysis through its partnerships to shut down the Medicare fraud occurring through drug diversion.

CMS acknowledges NPI and Medicare Enrollment Inaccuracies

Audit of CMS Medicare Enrollment

According to an OIG Report (http://oig.hhs.gov/oei/reports/oei-07-09-00440.asp), inaccuracies were found in Medicare enrollment databases that CMS is charged with oversight and collection of data.  In order to enroll in Medicare, providers must supply their NPIs and other information to CMS to be entered into the Provider Enrollment, Chain and Ownership System (PECOS). Accurate, complete, and consistent provider data in NPPES and PECOS help to ensure the integrity of all health care programs. Previous OIG review has revealed ongoing problems with CMS's oversight of provider data, sometimes resulting in improper Medicare payments to fraudulently enrolled providers.  

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CMS Delays Edits to Ordering/Referring Providers Not Enrolled In Medicaire


CMS temporarily delayed the implementation of edits relating to ordering/referring practitioners who were not enrolled in Medicare and were scheduled to go into effect May 1, 2013. CMS believes this rule will improve its ability to detect new fraud schemes and help ensure fraudulent entities and individuals do not enroll in or maintain their enrollment in the Medicare program.  Comments to the proposed rules can be submitted through June 28, 2013.

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Federal Watch List for Special Focus SNF: Can lead to CMS Exclusion

skilled nursing facilities federal watch list

The special focus status is meant to push Nursing Homes to fix underlying problems found in inspections, or face exclusion from Medicare and Medicaid programs. Nursing homes put on the Special Focus Facility list receive increased attention and inspections.

HHS/OIG Fraud Alert

HHS/OIG exclusion list

The Department of Health and Human Services (HHS/OIG) issued a Special Fraud Alert for Physician Owned Entities.  The alert was issued to bring attention to the practice of physicians profiting from the sale of medical devices ordered by physician owners for Medicare and Medicaid patients.

CMS to Deny Claims when Ordering or Referring Provider Not Enrolled in Medicare

Opted out from Medicare

Effective May 1, 2013, the Centers for Medicare & Medicaid Services (CMS) will begin to deny Part B Durable Medical Equipment (DME) and Part A Home Health Agency (HHA) claims for services or supplies when the ordering/referring practitioner (1) does not have a current Medicare enrollment record with a valid National Provider Identifier (NPI) or (2) is of a type that is not eligible to order or refer for Medicare beneficiaries.

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OIG Exclusion - Medicare Overbilling

OIG Exclusion List

On February 20, 2013, the Department of Justice announced that Jeffrey Sponseller of Agusta, Georgia, plead guilty to submitting over $800,000 in fraudulent claims to Medicare.

HHS-OIG Intensify Health Care Fraud Investigations

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Earlier this month, Nichole Eckert was convicted was found guilty of one count of conspiracy to commit health care fraud.  Judge Patricia A. Seitz in the Southern District of Florida sentenced Eckert yesterday to serve 48 month in prision.  In addition, Eckert was ordered to pay over $72 million in restitution along with her co-defendants. 

Medicare Fraud Leads to OIG Exclusion List

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Lori Jo Mueller was charged on January 9, 2013 in Minneapolis Federal court with health care fraud.  According to the charges, Ms. Mueller embezzled over $800,000 from June 2006 through June 2012.  If found guilty of the charges, she will be placed on the OIG exclusion list.

Ms. Mueller was hired in 2002 by Edilweiss Home Health Care and was eventually promoted to Vice President of Operations.  Her responsibilities included bookkeeping, financial accounting, and managing accounts payable.  The charges against her accuse her of using her access to the corporate checking account to embezzle the money.

In order to cover up her embezzlement, she purportedly submitted false claims to a Minnesota Medicaid and multiple other insurance carriers in order to create a pattern of double billing that allowed her to replace the monies she had embezzled from the corporate checking account.  The overbilling she conducted raised more than $600,000 in proceeds from 2006 through 2012. 

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