Grassley Works to Fight Fraud, Reduce Medicare Paperwork
WASHINGTON – Sen. Chuck Grassley, chairman of the Committee on Finance, todaysought guidance from government agencies about their efforts to fight Medicare fraud and reducethe regulatory burden on Medicare providers.
“It’s important to strike a balance between easing the regulatory burden on Medicarecontractors and preserving the government’s ability to fight Medicare fraud,” Grassley said. “If wetip the scales too much toward easing regulations, we could unwittingly invite fraud. On the otherhand, if we’re too heavy-handed in enforcing fraud, we create headaches for a lot of well-meaningproviders. I think we can achieve a solution that meets both goals.”
Grassley and Sen. Max Baucus, lead committee Democrat, today sent letters to the GeneralAccounting Office and the Inspector General of the Department of Health and Human Servicesseeking guidance on how to ease the regulatory burden on Medicare providers without weakeninganti-fraud tools. Grassley and Baucus plan to work with the Committee on Finance to develop aproposal that would be included in a larger Medicare bill scheduled for mark-up in July.
Grassley is the Senate author of the 1986 whistleblower amendments to strengthen the FalseClaims Act, which is one of the government’s most effective weapons against fraud. In recent years,the False Claims Act has been especially useful in fighting health care fraud.
Copies of the Grassley-Baucus letters follow.
May 16, 2001
Michael Mangano
Acting Inspector General
Department of Health and Human Services
Office of the Inspector General
330 Independence Avenue, SW
Cohen Building, Room 5246
Washington, DC 20201
Dear Mr. Mangano:
The success of the Medicare program is dependent in large part upon the ability of health care providers to offerquality, efficient services to beneficiaries. As Medicare has evolved since its inception in 1965, and as the number of people being served has continued to rise, communication between the Health Care Financing Administration, program contractors, and providers has become an increasingly complex task. The Senate Finance Committee is committed to making common-sense adjustments to the program in order to facilitate better communication among the elements of the Medicare delivery system and to reduce the regulatory burden facing Medicare providers. The end goal is to free providers to practice medicine and enhance and maintain the health of Medicare beneficiaries.
On March 5, 2001, Senators Murkowski and Kerry introduced S. 452, the “Medicare Education and RegulatoryFairness Act.” The following day, companion legislation was introduced in the House of Representatives. We appreciate the efforts of our colleagues and the contributions being made to the Medicare modernization efforts. We believe all involved share a common goal of improving the program for beneficiaries and providers.
We have concerns, however, about the manner in which S. 452 and H.R. 868 have been drafted. As consistentand staunch advocates against Medicare fraud and abuse, we are concerned these bills will effectively block the ability of the federal government to maintain the integrity of the Medicare trust funds and even place at risk the health and wellbeing of Medicare beneficiaries.
In light of your office’s involvement in maintaining the integrity of the Medicare trust funds, we wouldappreciate receiving your responses to the following questions. Furthermore, we would ask you to offer any possiblesolutions to achieve the goal of decreasing the regulatory burden on Medicare providers while still ensuring the integrity of the Medicare trust funds and the sustainability of the program. We feel strongly that acting in any other manner would be a disservice to the millions of current and future beneficiaries who are counting on the program to meet their health care needs. A similar letter is being sent to Mr. David Walker at the General Accounting Office.
1. What percentage of Medicare claims are being billed correctly in any given year? To what degree has thepercentage changed in the years following the establishment of fee-for-service audits?
2. How many physicians are currently being prosecuted for fraud? How many physicians are currently underinvestigation? How does this compare with prior years?
3. The Medicare appeals process was amended for certain categories of providers, i.e. nursing homes and homehealth agencies. Could you comment on provisions in Section 521 of BIPA and indicate how you think thisprocess will operate? In addition, can you also comment on how you think the process outlined in Section102(b) in S. 452 will also operate? Would all categories of Medicare providers be eligible for the new appealprocess? Are the specified time frames for hearings workable?
4. Section 103 includes an exception using a “clear and convincing evidence” standard of proof. How does thelegal standard of “clear and convincing evidence” differ from current law? What impact could this standardbe expected to have on the ability of the federal government to collect overpayments through administrativeoffset?
5. Does S. 452 in any way directly impact the ability of the federal government to carry out the requirements ofthe False Claims Act?
6. Are there other anti-fraud enforcement implications in S. 452?
We look forward to your response as soon as possible. We greatly appreciate your cooperation and timelyresponse to this very important matter.
Sincerely,
Charles E. Grassley
Chairman
Max Baucus
Ranking Member
May 16, 2001
The Honorable David M. Walker
Comptroller General of the United States
U. S. General Accounting Office
441 G Street, NW
Washington, D.C. 20548
Dear Mr. Walker:
The success of the Medicare program is dependent in large part upon the ability of health care providers to offerquality, efficient services to beneficiaries. As Medicare has evolved since its inception in 1965, and as the number of people being served has continued to rise, communication between the Health Care Financing Administration, program contractors, and providers has become an increasingly complex task. The Senate Finance Committee is committed to making common-sense adjustments to the program in order to facilitate better communication among the elements of the Medicare delivery system and to reduce the regulatory burden facing Medicare providers. The end goal is to free providers to practice medicine and enhance and maintain the health of Medicare beneficiaries.
On March 5, 2001, Senators Murkowski and Kerry introduced S. 452, the “Medicare Education and RegulatoryFairness Act.” The following day, companion legislation was introduced in the House of Representatives. We appreciate the efforts of our colleagues and the contributions being made to the Medicare modernization efforts. We believe all involved share a common goal of improving the program for beneficiaries and providers.We have concerns, however, about the manner in which S. 452 and H.R. 868 have been drafted. As consistentand staunch advocates against Medicare fraud and abuse, we are concerned these bills will effectively block the ability of the federal government to maintain the integrity of the Medicare trust funds and even place at risk the health and wellbeing of Medicare beneficiaries.
We would appreciate receiving your responses to the following questions. Furthermore, we would ask you tooffer any possible solutions to achieve the goal of decreasing the regulatory burden on Medicare providers while still ensuring the integrity of the Medicare trust funds and the sustainability of the program. We feel strongly that acting in any other manner would be a disservice to the millions of current and future beneficiaries who are counting on the program to meet their health care needs. A similar letter is being sent to Mr. Michael Mangano at the U.S. Department of Health and Human Services Office of Inspector General.
Provider Education and Participation
7. What educational services are currently offered to Medicare providers and how can providers access theseservices?
8. How much is currently spent on Medicare provider education programs by HCFA and its fiscal intermediariesand carriers? Would S. 452, sec. 301(b), designate education funding for all Medicare providers or only aselected group?
9. What proportion of Medicare claims were billed correctly in FY 2000 and how does this compare with previousyears?
10. What are the implications for program integrity of having Medicare contractors disclose claims processingscreens as part of provider education?
11. Is there evidence that physicians are cutting back their participation in the Medicare program?Medical Reviews, Audits, and Appeals
12. What proportion of Medicare providers were subject to medical review in FY 2000 and how has this percentagechanged over the past 3 years?
13. Under current procedures, are there limits on the length of time a provider may be subject to prepaymentreview?
14. What are the implications of offering extended provider repayment periods on the federal government’s abilityto fully recover overpayments?
15. What are the respective roles and activity levels of Medicare contractors, DOJ, and HHS/OIG in conductingMedicare audits and investigations?
16. What is the status of cases currently in the fee-for-service appeals process? How would S. 452 affect theappeals process and Medicare providers eligible for appeals?
17. How many providers were prosecuted for fraud in FY 2000 and how has this number changed over the past 3years?
Recovery of Overpayments
18. In auditing samples of claims from which to extrapolate overpayment amounts, do Medicare contractors alwaysdraw statistically valid random samples? Are there ways to improve the sampling techniques used by Medicarecontractors?
19. How does the standard of “clear and convincing evidence of fraud” in S. 452, sec. 103, differ from the standardof proof currently required to determine provider fraud? What impact would this standard have on the abilityof the federal government to collect overpayments?
20. What procedures are currently in place for providers to voluntarily return overpayments? Could S. 452, sec.103, allow providers to return only a portion of the overpayment and be held harmless for the remainder?
21. What are the implications of offering extended provider repayment periods on the federal government’s abilityto fully recover overpayments?
22. What rate of interest does HHS charge providers on outstanding payments and how does this compare withinterest rates charged by the IRS and other federal agencies? Under S. 452, sec. 104, would HHS be allowedto assess an interest penalty while an appeal is in process?
Other Legal Issues in S. 452
23. How does S. 452, sec 3, define a “provider of services”? Are there provisions in the bill that providedifferential treatment for some Medicare providers?
24. Is it more difficult to challenge a Medicare regulation in court compared to other federal regulations? Howwould S. 452, sec. 102, affect an entity’s ability to challenge Medicare regulations?
25. How might S. 452 affect the federal government’s ability to use the False Claims Act in regard to Medicarepayments?
We look forward to your response as soon as possible. We greatly appreciate your cooperation and timelyresponse to this very important matter.
Sincerely,
Charles E. Grassley
Chairman
Max Baucus
Ranking Member
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