Medical facilities and durable medical equipment suppliers are the most likely to be a subject of Medicare, Medicaid, or CHIP criminal fraud, according to a study by the U.S. Government Accountability Office.
About one-quarter of the 7,848 subjects investigated in criminal healthcare fraud cases were medical facilities or were affiliated with them. About 16 percent of subjects were durable medical equipment suppliers, and roughly 3 percent of beneficiaries of healthcare programs were investigated in criminal fraud cases.
Of the 1,086 subjects charged in criminal fraud cases, roughly 85 percent of them were found guilty, pled guilty, or pled no contest to some of the criminal charges against them.
Among those subjects that were found or pled guilty or no contest, the most frequent subjects were medical facilities—18.7 percent—or durable medical equipment suppliers—18.5 percent.
About 11 percent of the subjects found guilty or who pled guilty or no contest were beneficiaries of healthcare programs. Among the 925 subjects that were found or pled guilty or no contest, 103 subjects were beneficiaries.
Hospitals accounted for roughly 20 percent of the 2,339 subjects of civil fraud cases investigated in 2010. Other medical facilities accounted for about 18 percent of the subjects, while less than 1 percent of those involved in civil healthcare fraud cases were beneficiaries of healthcare programs.
According to the same study, hospitals and medical facilities were found to be the most frequent subjects of civil fraud cases.
Approximately 47 percent of subjects were involved in civil cases that were pursued and the remaining 53 percent were involved in cases that were not pursued for a variety of reasons, including lack of resources or insufficient evidence
According to the 2010 data, 1,087 subjects were involved in civil fraud cases that were pursued, and among those, 602 subjects were involved in cases that resulted in a judgment or settlement for the government or the relator.
Congress has provided funds specifically for activities to address fraud in Medicare and other federal healthcare programs since 1997, most recently $608 million in funding to investigate and prosecute in FY2011.
The GOA’s suggestions for fraud prevention include: Strengthening provider enrollment processes and standards, improving pre- and post-payment claims review, and developing a robust process for addressing identified vulnerabilities.
Click here to read the complete study and GOA explanation of prevention methods.
Source:
http://healthcare.dmagazine.com/2012/11/30/goa-medical-facilities-most-likely-subjects-of-criminal-insurance-fraud/