Improper Payments Research Articles

Issues and concerns on statutory bodies and federal government - evidence from Malaysian Auditor General's report

This study aimed to identify the common issues frequently raised in the Malaysian Auditor General's reports, its particulars or descriptions and to investigate whether the levels of inefficiencies quoted in the Auditor General's reports keep increasing or decreasing in the period of this study. This study was based on secondary data and was supported with the feedback report received from the ministries, departments, state governments, government agencies and bodies in Malaysia, and also through Malaysian National Audit Department website in the section of auditor general's report for statutory bodies and federal government. This study found that the wastage in resources is the most critical issues faced by the government. It represents one-third or 36% from all of the issues examined in the Auditor General Report for the period of 2011 to 2013. Accordingly, this issue was also the highest issue commented in both statutory bodies and federal government. The other issues highlighted by the auditor general include poor job quality, unreasonable delay in job completion, improper payment, and unreasonable project price.

Decreasing Improper Payments in a Complex Federal Program

AbstractSince the early 2000s, the U.S. federal government has placed increasing focus on combating improper payments. Implementing policies to control improper payments is no easy task. Federal programs are often large, complex, riddled with moral hazard concerns, and jointly implemented. In 2011, the U.S. Department of Labor adopted a national strategy to combat improper payments in the Unemployment Insurance program. This article examines the effect that the Department of Labor's strategic initiative had on lowering states’ improper payments. Findings show that two of its tools—mandatory cross matching of employment records between the National Directory of New Hires and State Directories of New Hires and a communication strategy known as messaging—played a statistically significant role in halting the rise of improperly paid unemployment insurance claims. These results suggest that information technology tools and increased communication among stakeholders can be effective in lowering improper payments and improving government performance.

Home Health Chains and Practice Patterns: Evidence of 2008 Medicare Reimbursement Revision.

Home health agencies (HHAs) are known to exploit the Medicare reimbursement schedule by targeting a specific number of therapy visits. These targeting behaviors cause unnecessary medical spending. The Centers for Medicare & Medicaid Services estimates that during fiscal year 2015, Medicare made more than $10 billion in improper payments to HHAs. Better understanding of heterogeneous gaming behaviors among HHAs can inform policy makers to more effectively oversee the home health care industry. This article aims to study how home health chains adjust and adopt new targeting behaviors as compared to independent agencies under the new reimbursement schedule. The analytic data are constructed from: (1) 5% randomly sampled Medicare home health claim data, and (2) HHA chain information extracted from the Medicare Cost Report. The study period spans from 2007 to 2010, and the sample includes 7800 unique HHAs and 380,118 treatment episodes. A multivariate regression model is used to determine whether chain and independent agencies change their practice patterns and adopt different targeting strategies after the revision of the reimbursement schedule in 2008. This study finds that independent agencies are more likely to target 6 and 14 visits, while chain agencies are more likely to target 20 visits. Such a change of practice patterns is more significant among for-profit HHAs. The authors expect these findings to inform policy makers that organizational structures, especially the combination of for-profit status and chain affiliation, should be taken into the consideration when detecting medical fraud and designing the reimbursement schedule.

Empirical Assessment of Good Governance in the Public Sector of Malaysia

IntroductionThe transformation of Malaysia from a developing country to a developed one is ongoing. Only four years to go before 2020, the year when Malaysia is targeted to become a fully developed nation. Vision 2020 is a program that encourages Malaysia to develop economically, socially, and politically through the enhancement of government systems, social and spiritual aspects, and national satisfaction and confidence (The Malaysian Digest, 2014). Good governance is considered as an important element to achieve Vision 2020. Strategies have been introduced to improve the quality of good governance in the Malaysian public sector, while cultivating integrity across all segments of the country (The New Straits Times Online, 2014). Many reform initiatives have been conducted since 1980s, such as ''Clean, Efficient and Trustworthy'', ''Integration of Islamic Values'', ''Excellent Work Culture'', ''Code of Work Ethics'', ''Client's Charter'', and ''ISO 9000''.Moreover, the Malaysian Institute of Integrity (MII) was established to cultivate compulsory human capital and knowledge resource within the civil sector (Rusnah et al., 2011). The National Integrity Plan (NIP) aimed to mitigate corruption, misconduct, misuse of power, and improve efficiency and effectiveness of the public delivery system by 2008. In 2009, Malaysia introduced a new approach toward transforming the government and public sector by focusing on six National Key Results Areas (NKRAs) under the Government Transformation Programs with the objective of changing the government machinery to be more effective in its service delivery and be accountable for outcomes that matter most to people as well as to aid the country in becoming an advanced, united, and just society with high standards of living. Administrative reformation to improve government accountability and strengthen the public sector was identified as the most important area for the benefit of the people and the progress of nation, as well as a crucial step of the government to maintain public confidence and the determination of the government in implementing good governance in the public sector.Despite efforts to improve service delivery, criticisms and complaints toward public service remain to be heard. The public sector continues to face criticisms for its inefficiency, red tape, lack of flexibility, ineffective accountability, and poor performance for a long period of time (Siddiquee, 2006). Moreover, Malaysians are still under the impression that the public sector is easily manipulated by malevolent people, and this perception has dampened public confidence in government institutions that allegedly practice corruption in government procurement and in business transfers at the local municipal level and demonstrate land excision abuse and land transfer fraud (The Star, 2008). According to Iyer (2011), poor service delivery reflects gaps in accountability, inequalities in policy planning, and inadequate coordination across public agencies. Furthermore, a number of issues in Malaysia's public sector are on accountability, integrity, and ethical behavior.These issues had been highlighted prior to 2012 in the report of the Auditor General, including issues on the negligence of public officials who fail to uphold their duty of protecting government interest. Several weaknesses have also been observed during the audit, including improper payment, overlooked specifications or low-quality/unsuitable items in procurement, unreasonable delays, wastage, weaknesses in revenue management, and management of governments assets (National Audit Department, 2013). The report further discussed that the weaknesses are due to the negligence of officers, such as their inability to comply with the rules and regulations, lack of monitoring, lack of project management skills, and failure to attend to the outcome/effect of programs/activities/projects, resulting in the wastage of a significant amount of money. …

How to Document Psychotherapy Sessions

Back to table of contents Previous article Next article Professional NewsFull AccessHow to Document Psychotherapy SessionsEllen JaffeEllen JaffeSearch for more papers by this authorPublished Online:14 Sep 2016https://doi.org/10.1176/appi.pn.2016.9b8Although there are no official guidelines for documenting psychotherapy in patients’ medical records, providing such documentation is as important as providing it for evaluation and management (E/M) services.In May, a contractor for the Centers for Medicare and Medicaid Services (CMS) sent a document called a Comparative Billing Report (CBR) to more than 4,000 psychiatrists, comparing their billing practices for psychotherapy services with those of other psychiatrists in their state and across the United States. The CBRs cited previous reports on improper Medicare payments for psychiatry services and indicated that the reason the services were found improper was primarily due to insufficient documentation.Although many of the errors found in earlier assessments were made by nonphysician psychotherapists, the CBRs defined what constitutes appropriate documentation that all psychiatrists who treat Medicare patients will find useful. It is similar to guidance that APA has long given its members.Date of serviceDiagnosesThe time spent providing face-to-face psychotherapy with the patient and/or family members (For an encounter that also includes medical E/M services, the psychotherapy time should be differentiated from the E/M time.)The type of therapeutic intervention (for example, insight oriented, supportive, behavior modification)Target symptomsProgress toward achievement of treatment goals (This means, of course, that the patient record must include a treatment plan, although you do not need to refer to it in the documentation for each session.)For psychotherapy lasting more than 52 minutes (90837, 90838), the reason the session required this length of timePreviously, these seven items fulfilled the requirements for psychotherapy documentation, and when all were present, psychiatrists have not had problems when audited.The CBRs refer to documentation requirements that are consistent with those of two Medicare administrative contractors (MACs). One of them—Cahaba Government Benefit Administrators, which is the MAC for Alabama, Georgia, and Tennessee—requires three extra pieces of information: The degree of patient interaction with the therapistThe reaction of the patient to the therapy sessionAny changes in the patient’s symptoms or behavior as a result of the therapy session (This item is questionable since it is unlikely that such changes can be determined at the time the session is documented. Perhaps the MAC meant to refer to the previous session.)Keep in mind that notes about personal information that emerges during the psychotherapy session beyond the seven points listed above should not be included in a patient’s medical record. Personal notes taken during the session to guide future treatment should also be kept separate from the medical record. Under HIPAA, the patient’s insurer and the patient can legally access the medical record, but they cannot access your record. ■Ellen Jaffe is the manager of APA’s Practice Management HelpLine. ISSUES NewArchived

Beyond Polemics: Poverty, Taxes, and Noncompliance

The earned income tax credit (EITC) is the most significant earnings-based refundable credit in the U.S. tax system. Designed as an anti-poverty program, it is a social benefit administered by the Internal Revenue Service. The EITC reaches more than 27 million households annually. Studies show it has a positive impact upon the children whose families receive it. Despite its many positives, however, the EITC is a program that for years has been plagued by taxpayer noncompliance: the estimated rate of improper payments on EITC claims has ranged between 20 and 30%, totaling billions of dollars annually. Though it is believed that the majority of EITC noncompliance may be unintentional, public reports of misconduct and fraud add fuel to the political rhetoric about a revenue system in which nearly half of Americans pay no federal income tax.This article unpacks the rhetoric. It describes why the term “improper payments” is not synonymous with fraud. It places EITC noncompliance within the broader context of the U.S. “tax gap” and examines what intentional EITC noncompliance has in common with sole proprietor noncompliance. It explores motivations for intentional EITC noncompliance and also examines the role of inadvertent error in the overclaim rate. It describes the ways in which self-prepared returns present wholly different challenges than those completed by paid preparers.Building on the above, the article critiques the Internal Revenue Service for its shortcomings in administering and enforcing the EITC program. The article calls upon the IRS to continue pursuing unscrupulous tax return preparers, but also highlights the need to design meaningful sanctions to punish and deter unscrupulous individuals who self-prepare.The article addresses these concerns within a comprehensive proposal to increase the amount of information required from all taxpayers (whether self-prepared or using a preparer) at the time of filing. It builds upon theories of taxpayer noncompliance in arguing that greater due diligence requirements will reduce both intentional and unintentional EITC errors. The article also proposes a program that would allow first-time EITC claimants the option to submit substantiating documentation at the time of filing in order to receive an expedited refund.The article concludes that increasing due diligence requirements at the time of filing, coupled with slowing down the refund process generally, is a reasonable way to improve administration of the EITC program without unduly burdening low-income taxpayers.

Design Goes to Lunch – at the USDA

It's a case study—and a microcosm of design‐based innovation within the US federal government.The National School Lunch Program had two problems. It was rife with improper payments, and there were kids who qualified but were still going hungry. That's how the Innovation Lab got involved.

Recovery Audit Contractor audits and appeals at three academic medical centers.

Outpatient (observation) and inpatient status determinations for hospitalized Medicare beneficiaries have generated increasing concern for hospitals and patients. Recovery Audit Contractor (RAC) activity alleging improper status, however, has received little attention, and there are conflicting federal and hospital reports of RAC activity and hospital appeals success. To detail complex Medicare Part A RAC activity. Retrospective descriptive study of complex Medicare Part A audits at 3 academic hospitals from 2010 to 2013. Complex Part A audits, outcome of audits, and hospital workforce required to manage this process. Of 101,862 inpatient Medicare encounters, RACs audited 8110 (8.0%) encounters, alleged overpayment in 31.3% (2536/8110), and hospitals disputed 91.0% (2309/2536). There was a nearly 3-fold increase in RAC overpayment determinations in 2 years, although the hospitals contested and won a larger percent of cases each year. One-third (645/1935, 33.3%) of settled claims were decided in the discussion period, which are favorable decisions for the hospitals not reported in federal appeals data. Almost half (951/1935, 49.1%) of settled contested cases were withdrawn by the hospitals and rebilled under Medicare Part B to avoid the lengthy (mean 555 [SD 255] days) appeals process. These original inpatient claims are considered improper payments recovered by the RAC. The hospitals also lost appeals (0.9%) by missing a filing deadline, yet there was no reciprocal case concession when the appeals process missed a deadline. No overpayment determinations contested the need for care delivered, rather that care should have been delivered under outpatient, not inpatient, status. The institutions employed an average 5.1 full-time staff in the audits process. These findings suggest a need for RAC reform, including improved transparency in data reporting.

YZStack

YZStack is our developing solution which implements many well-established big data techniques as selectable modules and allows users to customize their systems as a process of module selection. In particular, it includes an openstack based IaaS (Infrastructure as a Service) layer, a distributed file system based DaaS (Data as a Service) layer, a PaaS (Platform as a Service) layer equipped with parallel processing techniques and a SaaS (Software as a Service) layer with popular data analytic algorithms. Layers of YZStack are loosely connected, so that customization of one layer does not affect the other layers and their interactions. In this paper, we use a smart financial system developed for the Zhejiang Provincial Department of Finance to demonstrate how to leverage YZStack to speed up the implementation of big data system. We also introduce two popular applications of the financial system, economic prediction and detection of improper payment.

Performance in the Public Sector: A Look at Federal Improper Payment Rates

Public administration scholars have often sought to determine the predictors of organizational performance. For example, Moynihan and Lavertu (2012) look at predicting the use of performance information as a function of PART scores, GPRA, and a set of individual characteristics. Additionally, Chun and Rainey (2005) measure organization effectiveness (an aspect of performance) using four separate perceptual measures: managerial performance, customer service orientation, productivity, and work quality. These studies add to our knowledge of both perceptions of organizational performance and PART scores as a measure of performance. However, the first set of results is possibly fraught with common source bias as both the dependent and independent variables of interest are measured with the same survey performance (Meier & O’Toole, 2013a, 2013b; Huselid, 1995; Favero & Bullock, 2014). The second set uses PART scores as a reliable indicator of performance, although scholars have also found this to be particularly problematic (Radin, 2006). The Office of Management and Budget’s (OMB) Improper Payment dataset (which examines approximately 100 federal programs from 2004-2011) provides an alternative measure to test the predictors organizational level performance. The improper payments measure focuses on performance in terms of minimizing errors, which is a conceptualization that has not yet been tested in the public management literature. This approach allows for an examination of changes in error rates over time by program, organizational-level characteristics might predict error rates, and employee perceptions to explain the variance in error rates.

Teaching Physicians About Fraud and Program Integrity

Program integrity (PI) is defined as a comprehensive strategy to prevent fraud, abuse, errors, and waste in the U.S. health care system. PI has the goal of eliminating improper payments for health care services. In 2012, the Institute of Medicine estimated that the U.S. health care system annually loses $765 billion to waste, including improper reimbursements for unnecessary services, excess administrative costs, inefficiently delivered services, egregious pricing of services, missed prevention opportunities, and fraud. The article by Agrawal and colleagues in this issue presents an excellent overview of the concerted efforts by the Centers for Medicare and Medicaid Services and other payers to ensure the integrity of the public and private health care reimbursement systems. Egregious examples of fraud and abuse are defined easily for physicians, and common administrative mistakes are rectified with better education in billing rules and documentation requirements. However, the more ambiguous areas of PI likely will remain difficult to address. With each episode of health reform, providers and payers are reminded of the current inefficiencies and inconsistencies under which the disparate reimbursement systems in the United States operate. Thus, it is increasingly important for physicians, payers, policy makers, product makers, and patients to collaborate and to collectively define and minimize waste in the U.S. health care system. This commentary reviews current challenges to educating physicians and physicians-in-training about PI and explores a PI education curriculum already in place at a large academic medical center that might serve as a model for other institutions.

Expanding Physician Education in Health Care Fraud and Program Integrity

Program integrity (PI) spans the entire spectrum of improper payments from fraud to abuse, errors, and waste in the health care system. Few physicians will perpetrate fraud or abuse during their careers, but nearly all will contribute to the remaining spectrum of improper payments, making preventive education in this area vital. Despite the enormous impact that PI issues have on government-sponsored and private insurance programs, physicians receive little formal education in this area. Physicians' lack of awareness of PI issues not only makes them more likely to submit inappropriate claims, generate orders that other providers and suppliers will use to submit inappropriate claims, and document improperly in the medical record but also more likely to become victims of fraud schemes themselves.In this article, the authors provide an overview of the current state of PI issues in general, and fraud in particular, as well as a description of the state of formal education for practicing physicians, residents, and fellows. Building on the lessons from pilot programs conducted by the Centers for Medicare and Medicaid Services and partner organizations, the authors then propose a model PI education curriculum to be implemented nationwide for physicians at all levels. They recommend that various stakeholder organizations take part in the development and implementation process to ensure that all perspectives are included. Educating physicians is an essential step in establishing a broader culture of compliance and improved integrity in the health care system, extending beyond Medicare and Medicaid.

Trends in the use and cost of chiropractic spinal manipulation under Medicare Part B

Background contextConcern about improper payments to chiropractic physicians prompted the US Department of Health and Human Services to describe chiropractic services as a “significant vulnerability” for Medicare, but little is known about trends in the use and cost of chiropractic spinal manipulation provided under Medicare. PurposeTo quantify the volume and cost of chiropractic spinal manipulation services for older adults under Medicare Part B and identify longitudinal trends. Study design/settingSerial cross-sectional design for retrospective analysis of administrative data. Patient sampleAnnualized nationally representative samples of 5.0 to 5.4 million beneficiaries. Outcome measuresChiropractic users, allowed services, allowed charges, and payments. MethodsDescriptive statistics were generated by analysis of Medicare administrative data on chiropractic spinal manipulation provided in the United States from 2002 to 2008. A 20% nationally representative sample of allowed Medicare Part B fee-for-service claims was merged, based on beneficiary identifier, with patient demographic data. The data sample was restricted to adults aged 65 to 99 years, and duplicate claims were excluded. Annualized estimates of outcome measures were extrapolated, per beneficiary and per user rates were estimated, and volumes were stratified by current procedural terminology code. ResultsThe number of Medicare beneficiaries who used chiropractic spinal manipulation grew 13% from 2002 to 2004, remained flat through 2007, and then declined 5% through 2008. An estimated 1.7 million beneficiaries (6.9%) used 18.6 million allowed chiropractic services in 2008. In inflation-adjusted dollars, allowed charges per user increased 4% through 2005 and then declined by 17% through 2008; payments per user increased by 5% from 2002 to 2005 and then declined by 18% through 2008. Expenditures for chiropractic in 2008 totaled an estimated $420 million. Longitudinal trends in allowed claims for spinal manipulation varied by procedure: the relative frequency of treatment of one to two spinal regions declined from 43% to 29% of services, treatment of three to four regions increased from 48% to 62% of services, and treatment of five regions remained flat at 9% of services. ConclusionsChiropractic claims account for less than 1/10th of 1% of overall Medicare expenditures. Allowed services, allowed charges, and fee-for-service payments for chiropractic spinal manipulation under Medicare Part B generally increased from 2002, peaked in 2005 and 2006, and then declined through 2008. Per user spending for chiropractic spinal manipulation also declined by 18% from 2006 to 2008, in contrast to 10% growth in total spending per beneficiary and 16% growth in overall Medicare spending.

THE ANALYSIS OF BOT STRATEGIES BASED ON GAME THEORY – CASE STUDY ON TAIWAN'S HIGH SPEED RAILWAY PROJECT

Uncertainty in a contract for some BOT (Build-Operate-Transfer) projects may allow an opportunistic developer to take advantage of information asymmetrical factors, long-term external changes, and agency dilemma to request renegotiation and to alter the contact after it has been awarded. Such requests often entrap the government in hold-up problems and result in improper payments to the developers and may even create general public dissatisfaction with a project. In this paper, the Game Theory model is used to analyze the Taiwan High Speed Railroad project to examine how developers implement different strategies at the various stages of a project to alter the contract's conditions in order to continually creating competitive advantage after they have been awarded the contract. This project developer is now facing serious financial difficulties. In this study, the financial information on the Taiwan High Speed Railroad operations was used as the foundation for conducting a simulation to calculate the project's value after this project began operation. The results will serve as reference to the best decision-making strategy for renegotiating costs in competition and cooperation so that a developer can select the optimum project offering the maximum reward. Also, the result will be offered to industries involved in market competition or act as an approach to establish future BOT policies on renegotiation.

2013 Medicare Proposal Outlines New Reporting Rules

2013 Medicare Proposal Outlines New Reporting Rules

Unequal Burdens in EITC Compliance

Lower income means harsher treatment from the government for taxpayers who claim the Earned Income Tax Credit (EITC). EITC claimants are audited more often than any taxpayers other than the very wealthy. More concerning, however, is that the IRS audits EITC claimants by correspondence examination in a manner that unduly burdens access to this refundable tax credit, a credit that often keeps lower income workers out of poverty. Improper payment law brings increased scrutiny to federal programs that issue erroneous payments. Because the EITC is alleged to have substantial improper payments, it is subject to federal improper payment law, which adds administrative process and burdens in hopes of diminishing erroneous payments. While other scholars have noted the relationship between improper payment law and the EITC, this article takes the unique view that improper payment law, instead of burdening EITC administration, could provide relief to the Service’s onerous EITC compliance methods.

Improper Medicare Payments

Improper Medicare Payments

Uncovering the Iceberg: Mandating the measurement of fraud in the United Kingdom

Having regard to the impact of the credit crunch on fraud, the 19% average cuts in public spending and the wide disparities in fraud loss data, this article will argue for the mandating of fraud measurement through the introduction of legislation in the United Kingdom. The proposed statute applies to both the public and private sectors and incorporates minimum standards of measurement accuracy and the publication of findings and subsequent reduction strategies. In support of this contention this paper offers empirical evidence provided by the United States (US) Improper Payments Information Act of 2002. Further options for change are also presented including developing the role of the National Audit Office and the creation of an infrastructure for knowledge management through the sharing of best practice.

What Every CEO Should Know About Medicareʼs Recovery Audit Contractor Program

Under the Affordable Care Act, President Obama expressed his support for the use of “high-tech bounty hunters” to help fight healthcare fraud in the Medicare and Medicaid programs (US Government 2010). President Obama was referring to the recovery audit contractors (RACs) employed by Medicare, tasked to identify and correct improper Medicare payments. Contractors are highly incentivized to identify payment errors as a result of their contingency-based compensation arrangements. RACs’ contingency rates range from 9 to 12.5 percent and are based on the principal amount recouped from or refunded to the provider or supplier. The fiscal landscape in healthcare today is severely overburdened by a litany of varying payment schemes, preadmission certification criterion, and regulatory mandates. In keeping up with these requirements, providers manage the deluge of thirdparty audits, all simultaneously requesting information (Blue Cross Blue Shield of Massachusetts 2009). The RAC can request up to 10 percent of Medicare discharges, but never more than 300 medical records (in certain cases, up to 500) every 45 days. Keeping abreast of the various cycles of audit and deadlines required to preserve the right of appeal is an arduous task, and while Medicare RACs continue to ramp up, providers prepare for a new wave of Medicaid and insurance company RAC audits. The RAC audit program began as a demonstration project under the Medicare Modernization Act of 2003 (MMA) (42 CFR §1395dd 2003). The intent of the project charged the RACs with identification of provider underpayments and overpayments due to payment errors (CMS 2004). RAC audits began in 2005, focused on overpayments, in the three states with the highest Medicare expenditures: California, Florida, and New York. The program was expanded in 2007 to Massachusetts, South Carolina, and Arizona. In June 2010, the Centers for Medicare & Medicaid Services (CMS) reported an astounding $693.6 million net return from those first six states over a period of three years to Medicare trust funds, with 85 percent from acute care hospitals (CMS 2010). During the demonstration project, providers appealed only 12.7 percent of denials, of which 64.4 percent were decided in the providers’ favor (CMS 2008). On the cusp of what was considered a huge success by CMS, the project became permanent under section 302 of the Federal Tax Relief and Healthcare Act of 2006.

Medically Unlikely Edits.

Medically Unlikely Edits.