HRD-92-76 Medicare: One Scheme Illustrates Vulnerabilities to Fraud

Pursuant to a congressional request, GAO provided information on Medicare's involvement with fraudulent medical laboratory operations, focusing on: (1) the extent of false claims paid by Medicare; (2) Medicare's success in recovering lost funds; and (3) Medicare's vulnerability to similar fraudulent activities. GAO found that: (1) although Medicare experienced some success in identification and prosecution of fraudulent laboratory operators, many fraudulent claims were unrecovered; (2) physicians avoid liability for repayment by failing to respond to Health Care Financing Administration (HCFA) and carrier collection letters, stopping operations and forming new corporate identities, and using group practice billing; (3) recovering fraudulent claims concerning unnecessary tests remains difficult due to the required burden of proof; (4) pursuit of fraud cases through civil procedures is hampered by a lack of interagency cooperation and critical missing files; (5) inadequate monitoring of physicians' referral patterns, the ease of obtaining multiple provider numbers, and the failure of provider information regulations to exclude past violators continue to make Medicare vulnerable to fraud; and (6) some carriers have developed computerized claims edits to automatically suspend claims payments, and HCFA requires carriers to establish separate fraud investigations branches, but reduced Medicare funding may constrain and adversely affect investigations and reviews.