(8/23/08)- A recent report from the Office of Inspector General for the Department of Health and Human Services concluded that Medicare fraud is much more widespread than previous reports from Medicare had indicated.

The report scrutinized a program known as Comprehensive Error Rate Testing, or CERT, that audits a sample of Medicare claims submitted by sellers of durable medical equipment. CERT randomly reviews the medical records and other supporting documents to determine if Medicare has made correct payments.

AdvanceMed Corp., a subsidiary of Computer Science Corp., does the auditing for Medicare. The agency had previously reported to Congress that, for fiscal year 2006, AdvanceMed's investigators had found that 7.5% of claims paid by Medicare were not supported by appropriate documentation. The inspector general's review indicated that the actual error rate was closer to 31.5%.

The report alleges that AdvanceMed's auditors were told by Medicare officials to ignore government policies that would have accurately measured fraud. For example, auditors were told not to compare invoices from salespeople against doctors' records, as required by law, to make sure that medical equipment went to actual patients.

"This is outrageous," said Senator Charles E. Grassley, the top ranking Republican on the Senate Finance Committee, which oversees Medicare and Medicaid. " If heads don't roll, you can't change the culture of this organization".

(2/6/00)-The Justice Department's San Francisco office and the Inspector General of the Department of Health and Human Services announced that they had secured the largest settlement against a nursing home for fraud in a nursing home case. Beverly Enterprises Inc. the parent company of Beverly Healthcare, the nation's largest nursing home chain has agreed to pay a civil settlement fine of $170 million and to relinquish control of 10 of their homes in California. Their subsidiary, Beverly-California, will pay a $5 million criminal fine settlement.

Under the terms of the settlement Beverly will pay $25 million within 30 days to the government. The balance of $145 million will be deducted from Medicare reimbursements to the chain over an 8-year period of time. The settlement also included a corporate integrity agreement that provides for a reporting and compliance program to be overseen by the company and the Office of Inspector General.

The government's case alleged that Beverly had falsely inflated the number of hours nurses spent caring for Medicare patients at the 10 California homes and elsewhere. The government further alleged that the chain had submitted false nurse sign-in sheets and other fabricated documents to support the bills.

Beverly-California will plead criminally guilty to one count of fraud through an inter-state carrier in connection with a cost report relating to one facility, and 10 counts of making false statements to Medicare. The charges arose for the period of time from 1992 to 1998.

We urge our viewers to report to Medicare fraud to the proper authorities when they become aware of it. Cutting back on fraud not only saves the taxpayers money, but will mean a monetary reward for the "whistle blower" who helps bring the fraud to the government's attention, and there is a recovery of $100 or more. The fraud hotline telephone number is 1-800-HHS-TIPS or 1-800-447-8477.

FOR AN INFORMATIVE AND PERSONAL ARTICLE ON PRACTICAL SUGGESTIONS WHEN SELECTING A NURSING HOME SEE OUR ARTICLE "How to Select a Nursing Home"

By Allan Rubin
updated August 23, 2008

http://www.therubins.com

To e-mail: hrubin12@nyc.rr.com or rubin@brainlink.com

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