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| Deficit Reduction Act Section 1936: Centers for Medicare and Medicaid Services:Deficit Reduction Act (DRA)- section 1936 of the Social Security Act |
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by Victor N. Moturi, MBA, RHIA - February 7, 2012
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The rising healthcare cost has been partly attributed to fraud, abuse and waste. How can this be controlled? My quest to find an answer led me to the Centers for Medicare and Medicaid website. One particular statute caught my attention, the Deficit Reduction Act of 2005. I had to ask myself if just having legislations in place would be sufficient enough to control Medicaid fraud, abuse and waste throughout United States. The site revealed strategies this law can be enforced.
I thought the most interesting part of this site was where it spoke about reporting of fraud. Obviously if physicians understand this part of the legislation they have to be absolutely careful if they intend to indulge in fraud or abuse of Medicaid funds. Any suspicions of Medicaid fraud should be reported to appropriate Medicaid State Agencies; alternatively you can call the National Fraud Hotline. This made me ready to be a whistleblower. I felt I know what to do just in case I identified Medicaid fraud. The site gave me an idea of the basic information I need to have when calling the Medicaid State Agency or National Fraud Hotline. I know I should have the name of the Medicaid client, the client's Medicaid card number, the name of the doctor, hospital, or other health care provider and the date of service and amount of money that Medicaid approved and or paid.
The other interesting part of the site was the provider audit section. I thought this was the finest part of the Deficit Reduction Act of 2005. The idea of having auditors auditing your Medicaid claims should deter the physicians from committing fraud. Obviously the Audit will reveal overpayments. To satisfy the requirements of the Deficit Reduction Act the Department of health launched the Medicaid Integrity Program (MIP) which has the responsibility of procuring the Audit Medicaid Integrity Contractors (Audit MICs) to conduct the provider audits. These audits should reduce inappropriate Medicaid claims. Cases where physicians bill Medicaid beneficiaries for services that were never given should decrease. Note that before the audit the provider receives a notification letter stating that they have been selected for the audit. The provider will be required to gather the requested documents. Also, the providers and office personnel should be ready to be interviewed.
The site portrays the commitment of the U.S Government to fight fraud, abuse and waste of Medicaid funds. Under the Deficit Reduction Act of 2005 Congress increased resources available to CMS to combat fraud, abuse and waste in the Medicaid Program. The site gives us a perspective of how important it is to have skilled, experienced and well educated professionals doing the documentation and billing for Medicaid Programs at your facility. This will limit the potential citations and sanctions you might receive from the Audit Medicaid Integrity Contractors.
The Deficit Reduction Act is in line with other legislations like the Health Insurance Portability and Accountability Act (HIPAA) of 1996 which has provisions that set civil and criminal penalties for violations of its provisions. HIPAA has also created programs that control fraud and abuse within the health care system. The commitment of the U.S Government to combat fraud and abuse is reflected by these two legislations. For more information please visit the Medicaid Integrity Program site of the Centers of Medicare and Medicaid.[i]
[i] U.S Department of Health Human Services, Centers for Medicare and Medicaid (CMS).(2010).
Medicaid Integrity Program; general information. Retrieved from
https://www.cms.gov/MedicaidIntegrityProgram/ on September 13, 2010
Reference
U.S Department of Health Human Services (DHHS), Centers for Medicare and Medicaid (CMS).
(2010). Medicaid Integrity Program (MIP); general information. Retrieved from
https://www.cms.gov/MedicaidIntegrityProgram/ on September 13, 2010
Victor is a Registered Health Information Administrator (RHIA) by the American Health Information Management Association (AHIMA) since 2009. He has a Master of Business Administration (MBA) with a Health Care Administration Concentration and a Bachelor of Science in Health Services and Health Information Management.
The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.
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