The HEAT is On: Government Efforts to Tackle Medicare Reimbursement Fraud Protection Status
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by Glenda Motta RN, MPH

Say what you will about Obamacare, but the President has made eliminating fraud, waste, and abuse in healthcare a top priority. The Attorney General and Health and Human Services (HHS) Secretary recently released a report on health care fraud prevention and enforcement efforts in Fiscal Year (FY) 2011.1 Nearly $4.1 billion was recovered, the highest ever reported. The Health Care Fraud Prevention & Enforcement Action Team (HEAT) works to prevent fraud, waste, and abuse in the Medicare and Medicaid programs. Their efforts and other approaches are being expanded using tools authorized by the Affordable Care Act.

No one is immune and it is often shocking to learn who is committing fraud. One HEAT action charged 115 defendants in nine cities, including doctors, nurses, health care company owners and executives for their alleged Medicare fraud schemes involving over $240 million in false billing. A common fraudulent practice attributed to physicians, therapists, podiatrists, and clinics is “upcoding” services and “unbundling” procedures to obtain higher payment. Tisn’t prudent!

A new Fraud Prevention System uses advanced predictive modeling technology to screen all Medicare fee-for-service claims before payment. Much like the predictive technologies used in the credit card industry, it identifies suspicious behavior and billing irregularities. Other preventive measures focus on certain categories of providers and suppliers, including home health agencies, and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers.

Penalties are getting stiffer. One corporation owner was sentenced to 50 years of incarceration for his role in a Medicare fraud scheme, and convicted individuals and corporations are fined millions of dollars. Fraud and abuse takes many forms, so for a better idea of investigative activities, review the latest report by clicking here.

Other documents can be found at The Department of HHS and Department of Justice Health Care Fraud and Abuse Control Program Annual Report FY 2011 contains the hospitals, home health agencies, pharmacies, physicians, therapists, clinics, medical equipment suppliers, transportation providers, and device and pharmaceutical manufacturers fined for violations. Many familiar names appear!

So, be aware! Always refer to and follow published national and individual insurer coverage policies, Medicare contractor LCDs, American Medical Association CPT™ guidelines, the National Correct Coding Initiative, and other up-to-date resources:

1.The full text of this excerpted HHS press release (issued Tue Feb 14) can be found at:

About The Author
Glenda Motta RN, MPH is a reimbursement consultant and wound care expert, publishing over 125 articles and books, serving as the President of the WOCN (1987-1989), and founding GM Associates, Inc., a healthcare marketing and reimbursement firm.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.


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