Improving prepayment practices in order to prevent.
详细信息
- 作者：Hansen ; Paul D.
- 学历：M.S.
- 年：2014
- 关键词：Economic Crime Management ; Shannon Johnson ; entitlem
- 毕业院校：Utica College
- Department：Economic Crime Management
- ISBN：9781303795558
- CBH：1553384
- Country：USA
- 语种：English
- FileSize：765141
- Pages：67
文摘
When the Medicare amendments to the Social Security Act were enacted in 1965,the only government programs to provide healthcare benefits were either to active military or through the Veterans Administration (now called the Department of Veterans Affairs) for veterans and their families. The administration of the Medicare program,therefore,heavily relied upon the private sector. Contracts were awarded to intermediaries and carriers within the private insurance industry to manage the day-to-day processing of claims. Yet almost from the beginning fraudulent claims were being paid. Some studies indicate that almost 25% of Medicare overpayments in any one year were made to unlicensed or suspended providers and suppliers or on behalf of beneficiaries who had died prior to claims submission. With the current Medicare beneficiary population at 44 million and expected to nearly double by 2030,the program represents a large portion of the U.S. government's budget. This paper determined that there is no one billing system in place that can be accessed by all the carriers processing Part B Medicare claims. It examined the enrollment process used to qualify providers for participation and payment within the Medicare program and found numerous failed attempts to mandate that carriers verify information through various databases before allowing them to participate. The billing systems at the different carriers processing claims were determined to be incapable of detecting either providers who should not be submitting bills for reimbursement or bills for deceased beneficiaries. There are new prepayment technologies,such as predictive analysis,that are just starting to be used by processing contractors that have yet to prove their effectiveness.