CMS' unwieldy data hurts fraud prevention efforts

Perhaps you noticed that state Medicaid programs have taken over the news cycle lately, specifically in Florida, where there has been a contentious back and forth between the state and the federal governments. The battle reached its inevitable destination last week, when Florida filed a lawsuit against President Obama.

Regardless of how you feel about Medicaid expansion--or Florida's Gov. Rick Scott (R), for that matter--Medicaid programs should elicit even more elementary concerns. Thanks to insufficient data sharing capabilities, it appears federal and state healthcare programs are virtually clueless when it comes to controlling who can and cannot bill the program.

What's more, the Centers for Medicare and Medicaid (CMS) might not even be getting the basics right when it comes to fraud prevention, according to a Reuters special report. It shows that in 2014, more than 1,800 physicians who were banned from Medicare and Medicaid still submitted Medicaid claims in other states. All told, 32 states and the District of Columbia paid $79 million to 269 of those banned providers.

This is startling. It paints a picture of CMS as inept and chaotic, unable to even manage basic precautions to prevent inappropriate billing.

Physicians are removed from Medicare for two reasons: Fraud or quality concerns. Failing to follow through with those sanctions, and subsequently allowing physicians to further bilk the system, means the government's enforcement arm is merely chasing its own tail.

"We spend a lot of resources to identify bad actors, so this should be low hanging fruit," Blaine Collins, a deputy regional inspector general for the Department of Health and Human Services told Reuters.

It appears some of that fruit that has grown rotten on the vine.

Take Muhammad Choudhry, for example. In June 2011, he pleaded guilty to workers' compensation fraud after Ohio investigators found outrageous billing patterns for psychotherapy services, according to Reuters. Despite the fact that Ohio revoked his medical license and state billing privileges, Choudhry continued filling claims a couple states over in Illinois. In fact, on the same day that Choudhry was being sentenced in Ohio, he billed Illinois Medicaid for 131 patients. By the time Illinois caught up with him, Medicaid had already doled out more than half a million dollars.

There are many other head-scratching storylines, but, as usual, the cases we don't know about are more troubling than those that we do. Since Medicare and Medicaid data regarding banned physicians is so woefully inadequate, we don't actually know the true number of occurrences, although Reuters estimates it's in the "hundreds of millions of dollars."

We've heard a lot over the past several months about what the government is doing to prosecute fraudsters. False claims settlements are higher than they've ever been. More than ever before, the government is jumping in on whistleblower suits as an avenue for prosecution. 

It's clear the feds have put more resources towards fighting fraud, and higher recoveries indicate those measures are paying off, but it's all for naught without prevention. The knock against the feds has always been that although recoveries are growing, they haven't reached the point where they can stop fraud before it occurs, an approach that involves data analysis, or, at the very least, a cursory review of eye-catching billing practices.

Data has always been an unwieldy object for CMS, and watching the agency handle it brings to mind an infant clumsily grasping a handful of spaghetti. Until last year, the government fought the release of physician payment data, relenting only after losing a lawsuit to Dow Jones, the publisher of The Wall Street Journal. The data offered an inside look at millionaire physicians like Salomon Melgen. Just last week, the feds released a flood of data from CMS on Medicare Part D prescribing practices, a program that has been heavily scrutinized by ProPublica for its inability to curb wasteful and unnecessary prescribing practices, and in some cases, outright fraud.

The 2013 Part D data dump will likely yield some interesting results from analyst in the coming weeks. Like the physician payment data, it may lead to questions of fraud. For example, the top prescriber, Dr. Gavin Awerbuch, who billed Medicare Part D $16.6 million in 2013, was arrested last year for fraud and drug charges. His trial is scheduled for later this year.

I'm glad that the government is being more forthcoming with Medicare data, willingly or otherwise. But tucked behind the self-congratulatory rhetoric about transparency, you'll see subtle cries for help. Deputy Administrator of CMS, Sean Cavanaugh, told the WSJ that data dump will "help energize the private sector to help us improve our program."

If the private sector can help, so be it, but it shouldn't have come to that. Whether it's prescribing practices or banned physicians, the agency appears to be drowning in data, and now it's frantically reaching for an outstretched hand. Preventing banned physicians from billing other state Medicaid programs does not require a complicated algorithm or a Watson-style super computer, merely rudimentary data sharing capabilities that would draw snickers from any mildly successful tech start-up.

It clear by now that CMS has a data problem. Unfortunately, it's obstructing the path between fraud enforcement and fraud prevention. - Evan (@HealthPayer)