Article - June 26, 2008 - CCH

OIG reports billions in expected Medicare recoveries and exclusions of providers

The Office of the Inspector General (OIG) reported it conducted audits and investigations resulting in anticipated recoveries of $2.2 billion; exclusions of 1,291 individuals and entities for fraud and abuse involving federal health care programs; 293 criminal prosecutions for crimes against HHS programs, and 142 civil actions including False Claims Act cases, unjust enrichment suits, civil money penalties law (CMPL) settlements, and administrative recoveries related to provider self disclosure matters during the time period from October 1, 2007 to March 31, 2008. Also, long standing issues under review included Medicaid payment integrity; appropriateness of Medicaid and State Children's Health Insurance (SCHIP) payments; as well as recent focus on oversight of Medicare Part D; public health emergency preparedness and response; oversight of food, drug and medical device safety; integrity of information technology and systems; and ethics program oversight and enforcement.

Medicare Part D and B

CMS analysis of Part D data estimates revealed that Part D sponsors owe Medicare a net total of $4.4 billion for the 2006 program year. Eighty percent of the sponsors owed CMS money and 20 percent were due money. CMS also noted that there was no mechanism to collect funds oradjust prospective payments prior to reconciliation after close of the plan year. A review of Part D payments to local, community pharmacies, disclosed almost 97 percent of the time, drugs were acquired for less than the reimbursement amounts. OIG estimates that, Medicare Part D payments to local, community pharmacies exceeds the pharmacies' drug acquisition costs by 18.1 percent.

OIG estimates that Medicare Part B made a total of $106.9 million in potential overpayments to suppliers of outpatient services on behalf of beneficiaries in Part A covered skilled nursing facilities (SNF) during calendar year (CY) 2001 and 2002, due to no systems edits being in place. In CY 2003 edits were implemented and overpayments were reduced to $22.7 million

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