Is the Medicare/Medicaid waste and fraud cup half full or half empty? The latest reports from the office of Inspector-General Dan Levinson can be read either way. Take, for example, his auditors' findings on the billing practices of South Miami Hospital (SMH).
This South Miami facility is a 381-bed acute care hospital that received "approximately $116 million for 9,695 inpatient and 43,524 outpatient claims for services provided to beneficiaries during calendar years (CY) 2009 and 2010 based on CMS’s National Claims History data," according to the HHS IG.
The audit examined 69 inpatient and 76 outpatient claims worth $4.2 million. Here's what the HHS IG found when its auditors looked over those claims:
"The hospital complied with Medicare billing requirements for 85 of the 145 claims we reviewed. However, the hospital did not fully comply with Medicare billing requirements for selected inpatient and outpatient claims," the HHS IG said.
"Specifically, of 145 sampled claims, 60 claims had errors, resulting in overpayments totaling $468,323 for CYs 2009 and 2010. Overpayments occurred primarily because the Hospital did not have adequate controls to prevent incorrect billing of Medicare claims," the report said.
In other words, more than 40 percent of the audited claims contained errors. Extrapolate that to the $116 million in Medicare funds received by SMH during the covered period and it could involve something like $45 million in incorrect reimbursements by the government.
Does that suggest intentional fraud at some level or bureaucratic regulations so cumbersome and difficult to understand that high error rates are impossible to avoid? Or some of both factors?
For more from the HHS IG, go here.
Then there are those Power Mobility Devices (PMD) for elderly and handicapped persons that are regularly advertised on cable TV channels. Whenever government offers to pay for such a product, odds are a lot of people - not all of whom actually need it - will want to get in line for it or to be the supplier.
So, the HHS IG took a look at one such supplier, Marquis Mobility of Canton, Ohio, which supplied 1,140 PMDs between June 6, 2006, and June 30, 2009, for which the government paid the firm $3.9 million. Here's what the IG found:
"Of the 200 randomly sampled claims, 157 claims met Medicare requirements, but 43 claims did not. Specifically, Marquis Mobility did not provide adequate documentation to support the medical necessity of PMDs for 26 claims, all required documentation for 9 claims, and properly completed physician orders for 8 claims."
As a result, the HHS IG calculated that Marquis Mobility owed the government more than $680,000 in reimbursement for the improperly completed claims that represented almost a third of all those examined by the auditors.
Again, the question is whether the high error rate results from incompetence or malice on the part of the claim filer or is it a rotten fruit of excessively complicated bureaucratic regulations?
For more on the PMD issue, go here.