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  • Tom Boyd

Reporting Fraud & Abuse

Two Providers With Excluded Employees Faced Far Different Medicaid Consequences (excerpt)

AIS’s Health Business Daily, July 22, 2011

In two recent Medicaid recoupment cases, two organizations that committed the same violation had wildly different fates, apparently because of the way they interacted with the government.  Both Maryland-based organizations serve people with developmental disabilities and both had an employee who was excluded from Medicare and Medicaid.  But one organization self-reported and wound up repaying a modest amount, while the other organization lost all Medicaid reimbursement earned during the time it employed the excluded person… 

5 Percent of Patients Account for Half of U.S. Medical Bill

Remington Report NewsWire, July 6, 2011

The 5 percent of Americans with the highest health care costs were responsible for roughly half of all U.S. health care spending in 2009, according to a new report from the National Institute For Health Care Management.  The highest 10 percent of health care spenders incurred 63.6 percent of the total cost, the report also found.  On the other end of the spectrum, the 50 percent of Americans with the lowest health care costs accounted for just 3 percent of the total cost of health care in 2009.

Report can be found at:

CMS projects health spending growth, impact of ACA

AHA News Now, July 28, 2011

National health spending is expected to grow by a record low 3.9% in 2010, to $2.6 trillion, primarily due to slower growth in Medicare Advantage payments and lower private spending associated with the recent recession, the Centers for Medicare & Medicaid Services reported today.  CMS estimates spending growth will average 4.9% between 2011 and 2013 (including a 29.4% cut in Medicare physician payments in 2012 unless Congress intervenes) and 8.3% in 2014, when the Patient Protection and Affordable Care Act expands health coverage through Medicaid and state insurance exchanges.  The ACA is expected to increase health spending by an average 0.1 percentage point annually through 2020, while extending health coverage to nearly 30 million uninsured Americans.  CMS estimates spending for hospital care will slow to 4.6% growth in 2010 due to the recession and a continu ed decline in service use, and grow 7.2% in 2014 and 6.2% per year from 2015-2020.  The report was published online in Health Affairs

UnitedHealth report points to telehealth to ease rural healthcare crisis

Healthcare Finance NewsDay, July 27, 2011

The Minnesota-based insurer sees a greater need for healthcare in rural America, as well as an increase in people on government-funded insurance programs and a decrease in physicians, and points to telehealth and telemedicine as possible solutions.

Reporting Fraud & Abuse

The Office of the Inspector General (OIG) maintains a hotline, which offers a confidential means for reporting vital information.  The OIG Hotline accepts tips from all sources about potential fraud, waste, abuse, and mismanagement in Department of Health & Human Services’ programs.  The Hotline can be contacted:

By Phone1-800-HHS-TIPS (1-800-447-8477) By Fax1-800-223-2164 (no more than 10 pages please) By E-Mail By MailOffice of the Inspector General HHS TIPS Hotline P.O. Box 23489 Washington, DC 20026

Type of Complaints Accepted

  1. Billing Medicare/Medicaid for services not provided

  2. Kickbacks/inducements by healthcare providers

  3. Failure of healthcare providers to meet business requirements for participation in Medicare/Medicaid

  4. Direct solicitation of Medicare/Medicaid beneficiaries

  5. Failure of a Medicare private plan to provide contracted Service

  6. Other (please explain in your narrative description)

Unless you choose to remain anonymous please provide the following data:

  1. Your Name

  2. Your Street Address

  3. Your City/County

  4. Your State

  5. Your ZIP Code

  6. Your Telephone Number(s)

  7. Your email address

Complaint Information: Subject that the allegation is against.

  1. Name of Subject

  2. Title of Subject (if applicable)

  3. Subject’s Street Address

  4. Subject’s City/County

  5. Subject’s State and ZIP code

  6. Subject’s Telephone Number(s)

  7. Subject’s email address/website

  8. Narrative: Your comments need not be exhaustive but should include sufficient detail for a basic analysis of the complaint.

In addition to explaining the nature, scope, and time frame of the activity in question, please be sure you address the following questions (as appropriate):

  1. How you are aware of the alleged activity?

  2. Have you already reported the fraud, waste, and/or abuse?  If so, to whom?

  3. Have you suffered retaliation for reporting this activity?  If so, explain.

  4. Do you know of any potential witnesses to the activity?

  5. Do you have any documents or other physical evidence in your possession?  (You may attach samples to your complaint but please do not send original documents.)

  6. If you are reporting a suspicious charge from a Medicare Summary Notice, please include a copy of the Notice.


 An OIG analyst will review your complaint.  Not all complaints result in an investigation.  The OIG Hotline is not authorized to disclose any information on records in its possession:  the Hotline will not be able to confirm receipt of your complaint or respond to any inquiries about action taken on your complaint.  If you have identified yourself, a reviewing official may contact you for further information.  You have the option, however, of requesting records through the OIG Freedom of Information Act officer.

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