by William Van Ornum, Ph.D. on
An article in the Wall Street Journal examines how “Confidentiality Cloaks Medicare Abuse.” Mark Schools and Maurice Tamman report on how Medicare’s own internal regulations get in the way of effective review of claims that may be fraudulent.
“There are plenty of reasons why Medicare often fails to stop questionable payments up front. To protect law-abiding doctors and hospitals (the vast majority), Medicare is required to pay nearly everybody within 30 days. Medicare says it is reluctant to suspend payments to providers who may have made honest mistakes, out of concern that beneficiaries might go without needed treatment. Law-enforcement agencies and Medicare contractors, overwhelmed by the sheer volume of Medicare fraud cases, can’t investigate and prosecute them all. Sometimes, prosecutors and investigators ask Medicare to keep paying so as not to tip off targets of an investigation.
“But a central problem is that Medicare hasn’t fully exploited its most valuable resource: its claims database, a computerized record of every claim submitted and every dollar paid out.
“That’s really the crux of the issue,” said Kimberly Brandt, who led Medicare’s antifraud efforts from 2004 through June of this year. She said the program is “definitely on the right path” to making better use of its database, “but it’s not going to be a flip of the switch or an easy transition.”