Government Accountability Office Alerts Congress to Medicare & Medicaid Eligibility Issues

In fiscal year 2014, American taxpayers footed a $554 billion dollar bill for Medicare and Medicaid – two programs that, while essential in nature, are exceedingly strapped for resources. As one of the hallmark goals of the False Claims Act, authorities have worked diligently to ensure providers are billing correctly only for those services actually rendered, or major fines and penalties will ensue.

However, in a separate but related matter to upcoding and illegal billing, the Government Accountability Office (“GAO”) recently released an alert to Congress[1. GAO Report, June 2015. http://www.gao.gov/assets/680/671021.pdf] highlighting the fact that many recipients of Medicare and Medicaid reimbursements may not even be eligible for enrollment in the program in the first place. In this scenario, a provider could consistently bill correctly, but if they are not eligible to treat Medicare or Medicaid patients, the provider could still face False Claims Act liability.

Details of the GAO’s report to Congress

According to a report entitled “Additional Actions Needed to Improve Eligibility Verification of Providers and Suppliers,” the GAO opines that as many as 22 percent of Medicare providers are not actually eligible for enrollment in the program.[2. “This Week in Fraud,” Taxpayers Against Fraud Education Fund. July 24, 2015.  http://taf.org/blog/week-fraud-13] More specifically, the report highlights that the Center for Medicare and Medicaid Services (“CMS”) is not using the most up-to-date technology to detect fraudulent or ineligible addresses, including:

• P.O. boxes
• Commercial Mail Receiving Agencies (e.g. UPS Store boxes)
• Invalid addresses
• Nonexistent locations

As part of its report, the GAO urged Congress to amend the regulations of Medicare providers to require that verification take place over the telephone to ensure an actual, physical practice location.

In a random sampling of 496 addresses, 120 were deemed to be ineligible. Many of these had not been updated in the past several years and the GAO reported that 29 of these were actually vacant properties.

GAO addresses licensing concerns

Of particular concern to the GAO was the seemingly rampant enrollment of providers who were not in good standing with their state’s medical board. Obviously, any physician enrolled in Medicare must hold an active license to practice medicine. Any adverse rulings by the state medical board – such as a suspension or revocation – must be immediately self-reported to CMS. In 2014, CMS updated its regulations to require regular checks of physicians’ license status; however, the GAO’s report contains startling data revealing that a significant number of unlicensed providers are continuing to collect reimbursement from the government.

Currently, there are approximately 1.3 million physicians deemed eligible to treat Medicare patients. However, the GAO was able to identify 147 doctors who did not have a license to practice due to the commission of felonies, crimes against patients, or financial misconduct. Most concerning, 74 of these physicians continued to bill Medicare after losing their licenses due to crimes like sexual assault, battery, rape, harassment, abuse, and patient intimidation.

Contact Berger Montague

Healthcare fraud is a serious crime that drains valuable government resources. If you are aware of fraudulent or suspicious activity by your healthcare provider or employer, please do not hesitate to contact Berger Montague today.