Medicare audits hurt providers, lawmakers complain

Efforts to fight fraud in the nation’s massive health care program for seniors have burdened many honest providers, pushing some out of business, lawmakers complained Tuesday.

At a House subcommittee hearing held by Rep. James Lankford, Democrats and Republicans grilled a White House administration official about Medicare payment audits dragging on for years. Some health care providers who appeal a decision against them must wait years for a resolution.

One congressman said the backlog of appeals could reach 1 million cases by the end of this year.

“At what point does it become a crisis?” said Rep. Mark Meadows, R-N.C. “When do you start putting companies out of business — because you already are? When does it become a crisis that you’re willing to do something about?”

Meadows said the process used to audit Medicare payments presumes providers are guilty until proven innocent. Rep. Tammy Duckworth, D-Ill., said a lengthy and expensive audit of a business that provides prosthetics could drive the only such provider in an area out of business.

Lankford, R-Oklahoma City, said access to health care was a critical issue now.

“Anything that discourages a provider from continuing to stay open makes the problem worse,” he said.

There was no disagreement about the need to police Medicare payments.

The federal Centers for Medicare and Medicaid Services has estimated that improper payments in the last fiscal year neared $50 billion, with the vast majority in fee-for-service Medicare payments.

The government employs contractors to track questionable payments. For one type of audit, the contractor is paid on a contingency basis; Lankford said some providers refer to those contractors as bounty hunters.

Kathleen M. King, director of Health Care for the Government Accountability Office, took issue with the way some lawmakers characterized the audit process. Not all contractors are paid on contingency, she said, and the ones who are paid that way have equal incentives to find instances when Medicare underpaid a provider.

“I don’t actually think that the post-payment review starts off with the provider is guilty. … It’s not a criminal matter,” she said. “It’s a matter of either an overpayment or an underpayment. And I do think that (the Centers for Medicare and Medicaid Services) has a responsibility as stewards of the trust funds to make sure that claims are paid properly.”

Shantanu Agrawal, who oversees program integrity for Medicare and Medicaid, said less than 1 percent of the claims made to Medicare are subject to audits.

He said, “It is a real challenge in program integrity to make sure we are doing our job protecting the trust fund and at the same time doing as much as we can to lower the burden on providers and make sure that there are no access-to-care issues for our beneficiaries.”

Lankford agreed that the program had to ensure taxpayer money was not misspent. The goal, he said, was to get to a point where the agency could resolve issues before any payments are made rather than chasing the money afterward and having providers tied up in lengthy appeals.

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