Information on Medicare's Administrative Sanction Process As It Relates to a Practitioner

In response to a congressional request, the results of Federal and insurance company investigations of the medical and billing practices of a podiatrist and two medical service organizations were reviewed.

GAO found that the doctor has not received Medicare payments since he was excluded from the Medicare program in 1981 for providing services that exceeded his patients' needs and recognized health care standards. Because the doctor sold one of the medical services organizations in question and did not appear to be connected with the other, he is not receiving any Medicare funds through these entities. Under current law, an excluded doctor can hold a financial interest in a group practice that provides services to Medicare patients without affecting the eligibility of the group. However, the Department of Health and Human Services (HHS) has the authority to refuse to pay for the services of the excluded doctor. Proposed legislation would extend this authority to allow HHS to exclude payment to any entity or supplier of services in which a significant ownership or controlling interest is held by a person convicted of a criminal offense against Medicare or Medicaid. In a prior report, GAO pointed out the need to improve and speed up the exclusion process. Delays made the recovery of overpayments related to fraud more difficult. In addition, overutilizers have not been excluded from the Medicare program because of confusion about who should perform peer review of suspected overutilizers. Finally, the billing practices of some former associates of the podiatrist are being reviewed to determine whether they should be excluded from the Medicare program.