Eleven senators and representatives requested that the Government Accountability Office (GAO) to examine the coordination among auditors such as Medicare administrative contractors (MACs), recovery auditors (RACs), zone program integrity contractors (ZPICs) and comprehensive error rate testing contractors (CERT).

The bipartisan group asked that the GAO also look into CMS’ efforts to oversee the contractors “to ensure that they are working efficiently and effectively while guaranteeing that beneficiaries are receiving the care to which they are entitled,” a June 26 letter states.

GAO should study:

  • The processes CMS uses to determine whether contractors’ audit criteria and methodologies are valid, clear and consistent;
  • CMS’ coordination of contractors to prevent duplication of efforts and overlapping audits;
  • Steps CMS is taking to limit duplicative audits while ensuring contractors have the tools to pursue program integrity efforts; and
  • What strategic plan CMS has to coordinate and oversee audit activities.

The group includes Sens. Orrin Hatch, R-Utah; Max Baucus, D-Mont.; Tom Coburn, R-Okla.; Tom Carper, D-Del.; and Chuck Grassley, R-Iowa. Reps. Fred Upton, R-Mich.; Henry Waxman, D-Calif.; Cliff Sterns, R-Fla.; Diana DeGette, D-Colo.; Charles Boustany, R-La.; and John Lewis, D-Ga., also signed the letter. To read the letter, visit:

Recent Fraud News

  • A physician assistant at South Dallas Community Medical Center pleaded guilty to one count of conspiracy to commit health care fraud, according to the U.S. Attorney in the northern district of Texas. Cal Graves and medical center owner Dr. Daniel Leong would use pre-signed prescriptions that falsely represented that the doctor examined and diagnosed patients or supervised Graves exam or treatment when the physician did not do that. Graves could be sentenced to up to five years in prison and a $250,000 fine. Leong’s trial is set to start Oct. 9.
  • Altus Healthcare & Hospice of Atlanta will pay more than $555,000 to resolve False Claims Act allegations that it submitted false or fraudulent claims to Medicare and Medicaid for inpatient hospice services, which pay the highest reimbursement, according to the U.S. Attorney in the northern district of Georgia. Patients for whom Altus submitted inpatient hospice claims did not meet the requirements of needing pain control or acute or chronic symptom management.
  • Almost 50 people have been charged in connection with a scheme to divert and traffic $500 million of prescription drugs used to treat HIV, schizophrenia and asthma, according to the U.S. Attorney in the southern district of New York. The drugs were dispensed to Medicaid recipients in the New York City area then were sold into “collection and distribution channels that ultimately ended at pharmacies for resale to unsuspecting customers,” the U.S. Attorney’s office states. “The defendants and their co-conspirators profited by exploiting the difference between the cost to the patient of obtaining the prescription drugs through Medicaid, which was usually nothing, and the hundreds of dollars per bottle that pharmacies paid to purchase those drugs to sell to their customers.”

RACs Keep Quiet

No RACs posted issues in the last week.

About the Author

Karen Long is the compliance product manager for DecisionHealth and oversees products that relate to fraud and abuse and HIPAA compliance for physician offices and home health agencies, and accreditation compliance for hospitals. In her almost four years at DecisionHealth, Karen also has been the compliance editor and a reporter for Home Health Line, nation’s leading independent authority on home healthcare business, regulation and reimbursement.

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