By Christopher P. Young, Editor, G2 Compliance Advisor
Medicare fee-for-service (FFS) tops a list of 13 high error rate government programs estimated to have lost $106 billion during fiscal year 2013 to improper payments. According to the authors of a study by researchers at the Mercatus Center at George Mason University released on Jan. 12, based on the latest estimates by the government’s Office of Management and Budget, the data may indicate that government programs are simply too big and too complex to properly oversee. Each time a report such as this one is made public, it is often used to justify more onerous payment policies affecting honest providers and their ability to serve their patients.
Three of the top four money wasters, when measured by the revenue lost, included healthcare programs. Besides Medicare FFS, the other two were Medicaid and Medicare Advantage. In terms of revenue, those health care programs wasted $62.2 billion. The study authors remind readers that the amounts in the report are estimates and the authors of the study contend that they are mostly underreported.
Improper payments include things such as fraud, errors because the program rules are so complex, or simple clerical errors. Improper payments are the subject of audits conducted under the Centers for Medicare and Medicaid Services (CMS) Comprehensive Error Rate Testing (CERT) program. CERT audits are used to measure the accuracy of claims payment in the Medicare FFS program and are reported annually in government reports concerning health care fraud, waste and abuse.
Laboratories are familiar with CERT audits because an improper interpretation of CMS regulation in a CERT audit caused several years of problems over whether physician signatures were required on laboratory requisitions. Laboratories and other health care entities spend huge amounts of resources refuting or defending themselves against government audits, or refunding money they may not owe.