The July 2013 alert, Federal Government Aggressively Pursuing Health Care Fraud, stressed the importance of self-audits for health care providers. With the Obama administration taking a hard-line approach to repeat offenders and high Medicare billing physicians, self-audits are more important than ever. 

The government estimates that roughly ten percent of Medicare’s annual fee-for-service payments, or a whopping six billion dollars a year in payments, are improper. On Jan. 15, 2014, the Centers for Medicare and Medicaid Services (“CMS”) released a directive addressing its plans to crackdown on “recalcitrant providers” contributing to these improper payments. CMS defines “recalcitrant provider” as a provider “abusing the program and not changing inappropriate behavior even after extensive education to address these behaviors.” CMS plans to refer these repeat offenders to Daniel R. Levinson, the Inspector General with the United States Department of Health and Human Services (“HHS”), who has the authority to issue civil fines and exclude providers from Federal health care programs like Medicare and Medicaid. 

In an effort to identify recalcitrant providers, HHS has specific plans to focus on those physicians with the highest Medicare billings. HHS directed Medicare officials to target these physicians with high cumulative payments as a screening tool. According to Inspector General Levinson, Medicare should establish a cumulative payment threshold and all claims filed in excess of that threshold should be closely examined. Physicians practicing in internal medicine, radiation oncology, or ophthalmology are most likely to be affected by this heightened fraud-review policy. 

As it aggressively pursues health care fraud, the government ended a thirty-year policy prohibiting the release of data showing the payment amounts that individual physicians receive from Medicare each year. As of March 18, 2014, and for the first time since 1979,1 the government will decide whether to disclose the amount paid to physicians treating Medicare patients on a case-by-case basis. This new policy would increase the amount of information available to the general public. A number of parties, including employers, insurers, and consumer advocates, are pushing for the release of this information. 

There are big changes on the horizon for health care providers who receive funding from Federal health care programs. As the government closely monitors high Medicare billers and makes Medicare payment information publically available, health care providers must take the necessary steps to protect themselves from fines and penalties. Health care providers should make every effort to identify any billing issues and ensure compliance.