- CMS spent about $89 billion in improper Medicare and Medicaid payments in 2015, a HHS official told a House panel Tuesday. Ann Maxwell, assistant inspector general for evaluations at HHS' Office of Inspector General, made the comments in testimony to a House Ways and Means subcommittee on health.
- The error rate was largely driven by documentation errors and ACA requirements, argued CMS Deputy Administrator Dr. Shantanu Agrawal.
- A GAO report released Wednesday found 23,400 physicians out of 105,234 had "ineligible" or "potentially questionable" addresses.
OIG released a report earlier this month stating the administration had failed to keep improper Medicare fee-for-service (FFS) payments below the 10% threshold required by law during fiscal year 2015.
Agrawal explained CMS calculates the improper payment rate by sampling data from 17 states over a three-year period. The rate has gone up because of lack of complete state compliance with new ACA requirements, he said.
To address the problem, the agency is working with states to ensure they are clear on requirements by providing guidance, according to Agrawal. It has also given states access to Medicare and law enforcement data on request. But if that doesn't work then the federal government should start talking about how to hold states accountable, he added.
A subcommittee member pointed out that CMS had an improper payment rate of 5.8% in 2013, 6.7% in 2014, and 9.8% in 2015, while the private sector typically has a rate of 3.4%.
The fact that CMS does not have a goal for reducing the improper payment rate this year "blows my mind," Rep. Chris Collins (R-NY) said during the hearing. "We’re halfway into the year."
In contrast with those Medicare and Medicaid programs, a provider in the private sector can be removed from a network without evidence against them showing they have been fraudulent or abusive in billing, Agrawal noted.