Discussion for article #229562
This is actually a tricky problem. My wife works in a clinic with a lot of Medicare patients. Billing is complicated already, to say the least.
Nursing homes, clinics and hospitals may well be billing for prescriptions after a patient has died, even though those prescriptions were delivered (or simply ordered) while the patient was still alive. The 32 day window (exactly one day over the longest month) is probably designed to take care of that.
However, it seems like that billing window is being exploited, at least to a degree. But the challenge will be how to close the window without putting a serious burden on institutional providers.
I hope Medicare moves slowly and carefully to change the rules, to avoid another hit to an already highly burdened billing departments in medical institutions. It’s already a paperwork nightmare.
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This topic is of particular interest to me because I worked on the team that wrote the Medicare/Medicaid fraud/waste/abuse detection software implemented in 2009 and written into law as part of the ACA.
The level of Medicare/Medicaid fraud is epidemic. It had been pretty easy to submit fraudulent claims for procedures, drugs, services and medical equipment, and the enforcement was pitifully weak. The new software used the research and input from thousands of health care professionals to write metrics that would search for particular patterns - claims from dead doctors, or on behalf of dead beneficiaries, excessive claims for procedures and equipment (such as docs performing 60 operation a day or a patient receiving 10 wheelchairs, etc). Amazingly, prior to this time there were NO automated checks of any kind.
The providers and companies suspected of fraud are turned over to the FBI. As of 2010, over $6B in fraudulent claims had been recovered. It’s probably more by this time, but I haven’t kept up with it since retirement.
Part of the explanation for delays has to do with how the massive amounts of data are transferred from one federal system to another for comparison. Companies may be late in providing data. There are billions of records to process and the comparison has to be timed properly, usually once a month. So I can see how a 30-day lag would be shrugged off as “falling through the cracks.”
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