Improper Payments Research Articles

Pandemic profiteering at a time of crisis: Using python to detect fraud in covid-19 testing and treatment payments

During the pandemic, the Centre for Medicare and Medicaid Services (CMS) introduced blanket waivers and rule flexibilities to address rising COVID-19 cases. This included expanding telehealth services to urban areas and waiving certain reporting requirements, along with various testing options such as surveillance testing, school and workplace testing, self-tests, and testing in more inpatient settings such as nursing homes. The federal and state governments also covered COVID-19 testing, vaccination and treatment for the uninsured population, creating opportunities for fraud and unnecessary testing, double billing, kickbacks, and deceased billing, mainly for monetary gain, by unscrupulous healthcare providers. Using Python programming, the study adopted an unsupervised learning approach by employing Isolation Forest to detect healthcare providers who were anomalies in the payment for COVID-19, treatment and vaccination by the Health Resources and Services Administration (HRSA). Additionally, using official search enquiry into official U.S. government websites such as the FBI, USDOJ, and HHS-OIG, this study identified eight (8) fraud, waste and abuse schemes related to laboratory testing and treatment. The isolation forest algorithm, set at a 5% contamination level, identified 1,890 healthcare providers (7.64% of total claims) as being anomalies. These results support the recommendations given to the HRSA by the Office of Inspector General of the Department of Health and Human Services (HHS-OIG), emphasizing the need for identifying and addressing improper payments. Protecting public health resources requires preventing fraud in the healthcare industry. Strong education programs for healthcare workers are crucial, as are vigilant oversight and collaboration between federal and state agencies. Additionally, this study emphasizes how crucial it is to use official government resources—such as the FBI, HHS-OIG, USDOJ, and CDC—to efficiently detect and prevent fraudulent activities. In the wake of information asymmetry, calls for private‒public partnerships are needed to address fraud, waste and abuse in the healthcare industry.

Using artificial intelligence to improve administrative process in Medicaid.

Administrative burden across state-federal benefits programs is unsustainable, and artificial intelligence (AI) and associated technologies have emerged and resulted in significant interest as possible solutions. While early in development, AI has significant potential to reduce administrative waste and increase efficiency, with many government agencies and state legislators eager to adopt the new technology. Turning to existing frameworks defining what functions are considered "inherently governmental" can help determine where more autonomous implementation could be not only appropriate but also provide unique advantages. Such areas could include eligibility and redetermination of Medicaid eligibility as well as preventing improper Medicaid payments. However, while AI is promising, this technology may not be ready for fully autonomous implementation and instead could be deployed to augment human capabilities with robust safeguards until it has proven to be more reliable. In the meantime, the Centers for Medicare and Medicaid Services should release clear guidance around the use of AI by state Medicaid programs, and policymakers must work together to harness AI technologies in order to improve the efficiency and effectiveness of the Medicaid program.

Generative AI for analysis and identification of Medicare improper payments by provider type and HCPC code

The 2022 Medicare Fee-For-Service Improper Payments Report reveals an estimated $80.57 billion in improper payments, with a payment error rate of 15.62%. This paper uses generative AI to analyze and identify which provider types and HCPC codes are most strongly associated with these errors. The paper employs generative AI to produce two Python codes: one generates a time-series trend graph of Medicare improper payments from 2010 to 2022, and the other calculates the number of payment errors by provider type and HCPC code. These codes are designed for novice and non-programmers. Three datasets are used, such as Medicare Fee-for-Service Comprehensive Error Rate Testing dataset released on March 8, 2023, merged codes such as HCPC codes and PCT codes. The result suggests what systems should be improved to reduce Medicare improper payments. Generative AI is being introduced to help novice and non-programmers analyze Medicare improper payments with datasets, aiding researchers in conducting similar tasks in the future.

Medicare Advantage: Growth Amidst Mounting Scrutiny.

The Medicare Advantage Program, home to nearly half of the eligible Medicare population, has recently come under increased scrutiny. The Government Accountability Office called on the Centers for Medicare & Medicaid Services to monitor "disenrollment of MA beneficiaries in the last year of life, validate MA-provided encounter data, and strengthen audits used to identify and recover improper payments to MA plans." The House Subcommittee on Oversight and Investigations of the Committee on Energy & Commerce, dedicated a hearing to "Protecting America's Seniors: Oversight of Private Sector Medicare Advantage Plans." In addition, a recently conducted audit of the Office of the Inspector General of the Department of Health and Human Services raised concerns over "denials of prior authorization requests" and "beneficiary access to medically necessary care." In this article we consider the backdrop for the growing scrutiny of the MA program and the implications thereof to its future trajectory.

This deserves a Huh?

Research methodology To complete this case, students will need to access financial statements from the Securities and Exchange Commission’s webpage. The links are provided. Students will also need to review the conceptual framework that is typically covered in Intermediate 1 to respond to question 5. Case overview/synopsis This case is based on the three financial statement restatements that Weatherford International Ltd. made over an approximately 18-month period. The restatements were due to a fraud committed by manipulating the income tax accrual in the financial statements. The manipulation used was to overstate the amount of income used to calculate the dividend exclusion and then use a relatively high tax rate to calculate the resulting tax benefit. The tax rate used for the fraud was substantially more than Weatherford’s effective tax rate (ETR), which was a prominent part of the company’s strategic growth plan. The tax senior with the external auditors who reviewed the entry made for the dividend exclusion captured the inconsistency with the comment that “This [the entry] deserves a huh?” The case is intended for students in Intermediate 2, where financial statement restatements and their effect on the company’s financial statements are typically covered. During the years covered in this case, Weatherford was also under investigation for violations of the Foreign Corrupt Practices Act (FCPA). Weatherford’s FCPA violations included multiple instances of bribery, the inappropriate use of volume discounts, improper payments and kickbacks in the United Nation’s Oil for Food program. Weatherford received the eighth-largest fine in the history of FCPA violations (at that time) of $152m. Weatherford’s FCPA investigation expanded, and the company paid another $100m in fines for violations of sanctions law and export control law. This case focuses only on the fraudulent manipulation of the financial statements through the tax accrual and does not delve into the other investigations. However, the linkage between those investigations and the fraud in this case is Weatherford’s nonexistent internal controls. Complexity academic level This case was designed to be used in Intermediate 2 financial accounting classes to highlight financial statement restatements and review the conceptual framework and materiality. The students who used the case did not have difficulty with the tax aspect of the case. However, most of the students had taken one tax class previously or concurrently. If students have not had any exposure to tax, the instructor might want to walk students through the tax aspects of the case.

Nuclear energy in Brazil: regulation, corruption, and prospects for energy generation

Abstract This article provides an overview of the historical development of the Brazilian nuclear regulatory environment and its implications for corruption in the nuclear energy sector. It explores Brazil's transition of nuclear energy policies from a military-centric approach to civilian perspectives following the country’s re-democratization in the 1980s. The article highlights the importance of nuclear energy diversification for stabilization and low-carbon energy generation in Brazil. It discusses the challenges and vulnerabilities of the Brazilian nuclear industry, focusing on the corruption scandal of 2015, revealing improper payments, mismanagement, bribery, and money laundering in constructing the Angra 3 nuclear power plant. The study proposes improvements in the corporate governance of the Brazilian sector to minimize potential corruption cases in future contracts. It analyses the conflict of interest among regulatory institutions, industry agents, and the corporate environment. This article also compares the Brazilian nuclear regulatory framework with international regulations and discusses strategies for combating corruption in nuclear power generation. The concluding remarks emphasize the need for institutional reforms to safeguard and develop the Brazilian nuclear industry.

Federal Enforcement of Pharmaceutical Fraud under the False Claims Act, 2006–2022

Context: The False Claims Act is the US federal government's primary tool for identifying and penalizing pharmaceutical fraud. The Department of Justice uses the False Claims Act to bring civil cases against drug manufacturers that allegedly obtain improper payment from federal programs. Methods: The authors searched the Department of Justice website for press releases published between 2006 and 2022 that announced fraud actions brought against drug companies. They then used the World Health Organization's Anatomical Therapeutic Classification index to identify the classes of prescription drugs implicated in fraud actions. Findings: During fiscal years 2006–2022, payments by six manufacturers amounted to more than 28% of total payments made as a result of federal False Claims Act actions. Nervous system and cardiovascular drugs were the classes of medications most commonly implicated in alleged fraud. Federal officials most frequently alleged that companies improperly promoted nervous system drugs and paid kickbacks to increase revenues from cardiovascular, antineoplastic and immunomodulating, and alimentary tract and metabolism drugs. Conclusions: Despite frequent pharmaceutical fraud settlements and penalties, incidence of alleged fraud among drug companies remains high. Alternative methods for preventing and deterring fraud could help safeguard our health systems and promote public health, and policy makers should ensure that effective fraud enforcement complements preventive public health regulation.

Preventive Tax Audit and Refunds Linked to the General Sales Tax of Exporting Companies in the Province of Tambopata, Peru

Objective: The objective of the scientific investigation was to determine the relationship between the preventive tax audit in the refunds linked to the general sales tax of exporting companies in the province of Tambopata, Peru. Method: The quantitative approach was considered, of a non-experimental type, with a descriptive and correlational design; considering a sample of 66 exporters from a universe of 80 to whom we applied two instruments, the first with 2 indicators and the second with 11, valid, with an alpha of 0.911 and 0.920 respectively. The statistical analysis was considered through the Pearson Chi square test and through a multiple linear regression. Results and conclusion: It were determined that the relationship between the preventive tax audit with the balance in favor of benefit, the perceptions not applied of the IGV and the excess or undue payments, is a high positive correlation. In view of the fact that, in the event of a 1% increase in the balance in favor of benefit matters, then the preventive tax audit will increase by 61.22%; if the non-applied IGV perceptions by the taxpayer are high, then the preventive tax audit will increase by 3.91%; and if the excess or improper payments increase by 1%, then preventive tax audit will increase by 15.47%. Finally, there is a high positive relationship between the preventive tax audit and the refunds linked to the IGV of the exporting companies of the province of Tambopata, since a Pearson correlation of 0.6957 was found. Implications of the investigation: The investigation shows an application of the theory to reality in the subject of the preventive tax audit in the returns linked to the general sales tax, the same that was carried out to the exporting companies of the province of Tambopata; all this in view of the fact that taxpayers and companies, when seeking to obtain greater economic profitability, avoid developing contribution actions with the State, since it is an obligation; That is why the supervisory and tax administration entities exercise the role of inspection, inspecting, investigating and controlling compliance with tax obligations. Originality/value: there are few investigations that analyze the relationship between the preventive tax audit with the refunds related to the general tax of the companies that are dedicated to the export of goods and services; which deserves to promote further investigations by types of exportable goods from Peru to the international market.

Compensation based on work relative value unit for cardiovascular surgeons in Iran: A mixed method study.

Work relative value unit (wRVU) is a tool for assessing surgeons' performance, compensation, and productivity. It appears that wRVU for cardiovascular procedures does not consider complexity and its value for lengthy operations is low. The aim of the study is to determine wRVU for cardiovascular procedures in Iran according to the proposed approach. This study was conducted as a mixed method in teaching hospitals in Tabriz in the period of September 2020 to December 2021. According to Hospital Information System and expert opinions, six procedures in cardiovascular surgery were included in the study. They were compared with 18 procedures in neurosurgery, orthopedics, and otorhinolaryngology in terms of the operation time and wRVU/min. Then, we calculated new wRVUs for the selected procedures based on surgeons' opinions, time measurements, and anesthetists' points of view by content analysis in qualitative and statistical analysis in quantitative parts. Among the six cardiac procedures, the wRVU for five was under-estimated. The wRVU/min value ranged from 0/28 to 1/15 in the studied procedures. Findings demonstrate no significant relationship between the length of operations and the wRVU announced by the Ministry of Health and Medical Education (P value >0/05). Compared to studied procedures in four specialties, thoracoabdominal aortic aneurysm repair has the longest surgery time at 417 minutes. According to anesthesiologists, cardiovascular; orthopedics; ear, nose, and tongue; and neurosurgery specialties obtained 4/2, 2/9, 2/8, and 4, respectively, in terms of surgery duration, complexity, risk, and physical effort. Despite policymakers' attempts to bring justice to payments, it seems that there has been little progress in paying cardiovascular surgeons. Improper payment to cardiovascular surgeons will affect the future of the workforce in this specialty. Today, the need to reconsider the wRVUs in heart specialty is felt more than before.

SOBE: A Fraud Detection Platform in Insurance Industry

Fraud detection identifies suspicious activities, false pretenses, wrongful or criminal deception intended to result in financial gain. Fraud is rare, well thought, effortful, and deceiving throughout claims. Detecting fraudulent claims is essential for the insurance industry. Therefore, most insurance companies must devote time and budget to fraud detection. Fraud detection can be divided into two categories; the main and most common type of fraud is individual fraud. Individual frauds can appear in many kinds of forms. For example, damage to an asset might be occurred before issuing a policy and be reported after. The second category is organized fraud which is much rarer and harder to detect than individual fraud. Especially motor insurance fraud is commonly attempted by organized crime rings. Counterparties involved in fraudulent claims change frequently, and changes make fraud detection difficult. According to Insurance Information and Monitoring Center findings, the fraudulent claim payment ratio is 10 to 30 %, and the detection success rate for an individual is at 1.4 to 5%. At the same time, the annual fraud cost is at 200 to 300 $ million. This study proposes a fraud detection platform called SOBE, which assists fraud departments’ claim inquiry more easily and shorter than manual investigation made by employees. At its core, SOBE uses a rule engine approach. In order to support the rule engine, there is also a machine learning algorithm for fraud detection. In addition, the SNA module detects interconnected fraud counterparts among claim files. Consequently, the SOBE fraud detection platform allows Anadolu Sigorta to prevent improper payments from claiming participants. SOBE platform, the central fraud detection platform at Anadolu Sigorta, was developed in-house using different technologies and methods, including KNIME Analytics Platform, Python, graph methods, and web service methodologies.

Dispute root causes and prevention in Iranian public-private partnership projects: a causal-predictive model

PurposePublic–private partnerships (PPPs) are notoriously prone to disputes among stakeholders, some of which may unduly jeopardize contract performance. Contract disputes arising in Iran are often due to inefficiency of PPP concession agreements and practice. This study presents a causal-predictive model of the root causes and preventive measures for inter-organization disputes to enhance the likelihood of achieving desirable performance in PPP projects.Design/methodology/approachA theoretical “causal-predictive” model was developed with fourteen hypotheses based on extant literature and contractual agency theory, which resulted in the creation of a pool of 110 published items. Data were obtained from a questionnaire survey with 75 valid responses, completed by 4 stratified groups of Iranian PPP experts. Partial least square structural equation modeling (PLS-SEM) was used for validating the proposed model via a case study.FindingsResults reveal that the main three factors of PPP desirable performance are as follows: on-time project completion, high quality of activities/products and services for public satisfaction. Further, the most influential factors of the lifecycle problems, construction stage, and preferred risk allocation included risk misallocation, improper payment mechanism and failure to facilitate a timely approval process.Originality/valueFor researchers, the findings contribute to the theory of contractual agency; specifically, how different influences among the model's elements lead to better PPP performance. In practical terms, proposed outcome-based strategies will inform PPP stakeholders to avoid dispute occurrence and thus improve the time, quality and services of projects.

지방계약의 책임성 제고를 위한 부패 유형과 개선방안 연구

It is necessary to enhance accountability of local government contracts due to the high risk of corruption. In previous studies, local government contracts have been continuously mentioned as one of the major fields of corruption in local governments. However, there are few studies that have specifically reviewed the corruption of local government contracts. Therefore, this study reviewed the corruption types of local government contract and improvement measures through analyzing the audit results of the Board of Audit and Inspection(BAI). As a result of the analysis, corruption in local government contracts occurred most frequently in the preparation stage as a procedure and in the field of construction as the object of the contract. Unfair private contracts were most common corruption types, followed by contract with the unqualified contract partners, improper cost calculation and payment and split contracts of single contracts. Characteristically, local government contract corruption are mainly caused by the actions of local public officials. And favorable treatment due to unfair contracts and contracts according to unfair instructions were also occurring. The lack of expertise of local public officials in charge caused corruption. Poor guidance and supervision of managers was also acting as a cause of corruption. Therefore, in order to prevent corruption in local government contracts, this study suggest necessity strengthening the internal control system, enhancing transparency, clarifying related laws and regulations, educating local public officials in charge and strengthening the roles of internal and external audits.

A perfect storm: how high levels of risk and weak internal controls resulted in violations of the foreign corrupt practices act

Theoretical basis This case is based on Weatherford International’s settlement with the Securities and Exchange Commission (SEC) and the Department of Justice (DOJ). Both the SEC and the DOJ were critical of Weatherford for its violations of the Foreign Corrupt Practices Act and for its “inadequate internal controls.” This case explores the Foreign Corrupt Practices Act (FCPA) violations and issues related to internal controls. Research methodology Case study. Case overview/synopsis This case is based on Weatherford International’s settlement with the SEC and the Department of Justice. Weatherford provided equipment and services in the oil and gas industry. Because international markets were growing faster than domestic markets, Weatherford made a strategic decision to pursue growth in international markets. The oil and gas industry has high levels of operating risk as did the countries that Weatherford decided to pursue operations in. However, despite the decision to take on additional risk, Weatherford failed to implement adequate systems of internal controls. The title of the case “A Perfect Storm” refers to Weatherford’s trifecta of operating in an industry with high levels of corruption risk, countries with high levels of corruption risk and failing to implement adequate internal controls despite those high operating risks (Department of Justice, 2013). Weatherford was ultimately assessed a $152m penalty for its violations of the FCPA that included bribery, volume discounts, improper payments and kickbacks. Complexity academic level Undergraduate and graduate auditing classes.

HHS/CMS Ongoing Efforts to Reduce Improper Medicare Payments

Payment & Practice Management| February 2021 HHS/CMS Ongoing Efforts to Reduce Improper Medicare Payments Sharon K. Merrick, MS, CCS-P Sharon K. Merrick, MS, CCS-P Search for other works by this author on: This Site PubMed Google Scholar ASA Monitor February 2021, Vol. 85, 26. https://doi.org/10.1097/01.ASM.0000733856.76241.99 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Cite Icon Cite Get Permissions Search Site Citation Sharon K. Merrick; HHS/CMS Ongoing Efforts to Reduce Improper Medicare Payments. ASA Monitor 2021; 85:26 doi: https://doi.org/10.1097/01.ASM.0000733856.76241.99 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll PublicationsASA Monitor Search Advanced Search Topics: medicare, united states dept. of health and human services When it comes to Medicare payment, recent focus has been on the conversion factors used to determine payment for services paid via the Medicare Physician Fee Schedule and the development of value-based payment systems. However, this has not changed the requirement that the Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS) take steps to reduce the incidence of improper payments per the Payment Integrity Information Act of 2019. Anesthesia and pain medicine practices should be aware of what services are considered particularly at risk for improper payments and the steps that HHS and CMS take to mitigate that risk. CMS did scale back its activities in this area from March to August 2020 due to the Public Health Emergency (PHE). Also due to the COVID-19 PHE, the 2020 analysis used claims dated from July 2018 to June 2019. The agency also adjusted... You do not currently have access to this content.

Constitutional right to pay – one of the most important socio-economic human rights

Problem setting. Remuneration is the main source through which the employee meets both their primary needs and the needs of a higher level. At a time when, on the one hand, the problem of meeting material needs is exacerbated, and on the other – the transition to market relations and building a socially oriented market economy in Ukraine requires a broader outlook and highly skilled workers, wages, its level, timeliness payments are brought to the fore by life itself. Remuneration is one of the guarantees of the realization of the constitutional right to work, and, consequently, one of the most essential rights of workers. Analysis of recent researches and publications. The issue of wages was the subject of research by such scientists as V.M. Bozhko, N.B. Bolotin, V.M. Weger, Y.M. Veres, O.V. Gaeva, N.D. Hetmantseva, S.Yu. Golovina, O.O. Ershova, M.I. Kuchma, L.I. Lazor, R.Z. Livshits, M.V. Lushnikova, A.Yu. Pasherstnik, O.I. Protsevsky, V.O. Radionova- Vodyanytska, N.M. Salikova, N.M. Khutoryan, E.B. Khokhlov, G.I. Chanisheva, O.M. Yaroshenko, and others. Target of research to consider remuneration as one of the guarantees of realization of the constitutional right to work. Article’s main body. The constitutional right to remuneration, as well as the right to work, is the most important socio-economic right of a person and a citizen, guaranteed by the Constitution of Ukraine, international legal acts and laws of Ukraine, which allows everyone to receive fair remuneration for their work. Despite the fact that the right to remuneration is constitutional, there are still many cases when this right is not respected and citizens are forced to apply to the authorities for protection, including non-payment or improper payment of wages. Conclusions and prospects for the development. The right to remuneration is characterized by the following features that determine its place in the system of constitutional human and civil rights enshrined in the Basic Law of Ukraine: a) is one of the fundamental human rights established by the Constitution of Ukraine, international legal acts and laws of Ukraine and recognized by most states the world; b) has economic and social components. The economic component is that a person can provide for himself and his family by means of subsistence. The social component is due to the fact that the state through a system of guarantees provides social assistance to workers and their families; c) is determined and guaranteed by the state through a system of legal guarantees; d) international normative legal acts, such as the Universal Declaration of Human Rights of 1948, the International Covenant on Economic, Social and Cultural Rights of 1966, the European Social Charter (revised) of 1996, and conventions play an important role in the realization of the right to remuneration. International Labor Organization, etc.; e) is guaranteed not only for citizens of Ukraine, but also for foreigners and stateless persons who are on the territory of our state on legal grounds.

Common patterns of corporate dermatology billing abuses in Medicare data sets

Advances in technology have brought about significant changes in the way physicians’ encounters are viewed. Patient charts once existed only in medical offices and hospital basements with medical billing done manually. Technologic changes have created new methods and expectations for oversight of the physician’s practice. This contribution examines the effects of data transparency on dermatology. Medicare has also responded with new requirements for quality reporting. The ability to recreate clinical encounters from freely available and physician-identifiable claims data has led to lawsuits, investigations by news outlets, and distrust in the medical judgment of physicians. The release of data has also uncovered possible improper payments that have brought these practices out of the shadows. Medicare data over the past few years also show evidence of rapid corporatization and consolidation, which is changing the practice of dermatology.

The ACA’s Medicaid Expansion: A Review of Ineligible Enrollees and Improper Payments

Enrollment in state-optional Medicaid expansions has significantly exceeded even the most optimistic forecasts. The open-ended federal financing of new adult Medicaid enrollees at elevated match rates — in excess of 90 percent — creates incentives for states and healthcare providers to improperly enroll new beneficiaries and inadequately monitor costs and eligibility. Several sources find that many states have done a poor job ensuring Medicaid enrollment only of those who meet eligibility requirements. First, several federal audits find massive problems with both incomplete and incompetent reviews and large-scale improper eligibility determinations. We summarize recent work that estimates causal effects of Medicaid expansions on enrollment. Using the publicly available American Community Survey, we demonstrate large increases in potentially improper enrollment from 2012 to 2017 in many expansion states across the United States. The evidence points to egregious eligibility errors in many states, including Arkansas, California, Colorado, Kentucky, Louisiana, Montana, New Mexico, New York, Oregon, Rhode Island, Washington, and West Virginia. Other expansion states have had much lower rates of improper enrollment. We offer recommendations to Congress, the Centers for Medicare and Medicaid Services, and the Congressional Budget Office on ways to confront improper enrollment in Medicaid, including both fundamental reform of program financing and meaningful federal oversight.

A Historical Evaluation of the Single Audit: Thirty Years from Initial Legislation to Uniform Guidance

ABSTRACT The U.S. government, through federal granting agencies (grantors), awards grants to state/local governments and nonprofit organizations (grantees) to meet national objectives. Since its initial legislation in 1984, the single audit has been used as a mechanism for ensuring accountability with these federal grants. Despite the consistent goal of accountability, concerns with single audit quality (i.e., whether audits reach appropriate conclusions) persist. In this historical evaluation of the single audit, we examine the major legislative and administrative developments associated with the single audit including (1) Single Audit Act of 1984, (2) Single Audit Act Amendments of 1996, (3) National Single Audit Sampling Project in 2007, (4) Improper Payments Initiative in 2009, and (5) administrative consolidation of all single audit circulars with Uniform Guidance issued in 2013. Understanding these developments should be helpful to researchers and policymakers in directing studies designed to better understand and improve single audit quality.

Medicare Loses Billions to Billing Errors

Medicare continues to improperly pay billions to physicians because of incorrectly billed claims. While inpatient hospital claims have recently (2017-2018) seen a reduction in improper payments, improper payments for physician outpatient services, particularly evaluation and management services (E/M), continue to see little or no improvement. Opinions vary on the causes of these billing errors and consequently on the appropriate countermeasures. Despite this national crisis, to date, no strategies have proven to improve billing accuracy for evaluation and management services. This research examines the existing literature to explore theories and constructs that explain causal factors of evaluation and management billing errors and to illuminate gaps in the research which if explored, may result in potential strategies for improving billing accuracy.

CVM을 활용한 해양스포츠의 경제적 가치 평가

The purposes of this study are to estimate the economic value of marine sports using CVM and to present the validity of investment in marine sports by the government and municipalities. Also, it is to provide the fundamental data to identify ways to increase the economic value of marine sports. In order to accomplish the study purposes, the study employed a CVM survey method with a total of 409 B metropolitan city residents over 20 years old who could have the capability to pay tax. The data were analyzed through SPSS 22.0. A binary logistic regression was modeled with a dichotomous dependent variable, willingness to pay (WTP). The independent variables such as gender, age, education, income, residence, experience and interest were input in the model. The economic value of marine sports was also estimated by using a model suggested by previous studies for CVM. Accordingly, following main findings are derived from the study. First, the logistic model for examining WTP determinants was statistically significant. Χ²(16, N=409)=57.120, p=.000 Cox and Snell R² and Nagelkerke R² were reported as .169 and .226 respectively. So, the model accounted for between 16.9% and 22.6% of the variation in WTP. Among the independent variables, gender, age, income, and interest were found to be the significant factors to WTP. Second, the mean amount of WTP was calculated as 2,191 won per person and the percentage of WTP was 50.7%. The annual economic value of marine sports was estimated as 18.95 billion won and the total value was 94.75 billion won. For non-payment reasons, ‘No financial leeway’ showed the highest frequency, followed by ‘No thought’, ‘Complaint on improper payment method’ and ‘High recommended amount’.