Medicare

Medicare continues to suffer large losses each year due to fraud. Existing risks are sharply increased by the continual growth in Medicare claims--both in number and percentage processed electronically. Existing Medicare payment safeguards can be bypassed and apparently do not deter fraudulent activities. The Health Care Financing Administration should be able to benefit by taking full advantage of emerging antifraud technology to better identify and prevent Medicare fraud. The number and types of Medicare fraud schemes perpetrated in South Florida may make that area the best place to test antifraud systems before nationwide use.

GAO found that: (1) Medicare's controls against fraud have not kept pace with the rising number of claims processed; (2) while electronic claims processing is critical for efficiency, the extreme volume of Medicare claims requires more innovative controls to curtail fraud; (3) existing Medicare controls have inherent limitations in detecting attempted fraud, since they are designed primarily to identify overutilized services; (4) there are new antifraud systems available to private insurers which recognize patterns in paid claims data and identify fraudulent relationships; (5) it is believed that these systems may be cost-beneficial in combatting emerging types of fraud; and (6) south Florida has been victimized by new types of fraud, resulting in the Health Care Financing Administration's (HCFA) formation of an interagency workgroup to identify specific problems and coordinate enforcement actions.

Recommendations

Our recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.

Director: Team: Phone: