A new report from the U.S. Department of Health and Human Services Office of Inspector General (OIG) showed that half of all the billings paid by Medicare in 2010 to community mental health centers for the partial hospitalization program were questionable.
In total, Medicare paid more than $218 million to CMHCs in 2010 for the partial hospitalization program (PHP), the intent of which is to allow patients to receive needed mental health services while also keeping them out of more expensive inpatient settings.
According to report author Latrice Rollins, the study was conducted since past OIG studies showed vulnerabilities in Medicare payments to CMHCs for these kinds of services. The work was spurred further by the conviction of four CMHC owners in Florida, who bilked the program of nearly $200 million via fraudulent PHP billings between 2002 and 2010.
"Past OIG studies revealed Medicare payments to CMHCs for beneficiaries who were not eligible for services and for services that were not needed," Rollins said in a podcast detailing her work. "Past OIG studies also found that 60 percent of states don't require these centers to be licensed or certified. This gives dishonest individuals an opportunity to create CMHCs and improperly bill Medicare."
The newest report, which studied the claims of 195 CMHCs across the country, found that most of the questionable claims came from just three states: Louisiana, Texas and Florida. Among the nine criteria used to ferret out improper billing was how far from the billing CMHC a patient lived. In one extreme case of a Florida CMHC the Medicare beneficiary listed lived more than 4,000 miles away in Hawaii.
But even outside that extreme example, Rollins said, the average distance of the beneficiaries for that center was 550 miles away. Another questionable claim characteristic related to the amount of time the beneficiary received services. A typical PHP claim would show treatment that lasted only a few days, but many of the claims discovered showed services being provided for as long as four months.
As a result of these and other discoveries, Rollins and her team made four specific recommendations to CMS to help improve the integrity of the program:
- increase monitoring of CMHCs' Medicare billing and fraud prevention controls;
- enforce the requirement that certifying physicians be listed on a CMHCs' Medicare claim;
- finalize and implement the proposed conditions of participation for CMHCs; and
- review and take appropriate action against those centers with questionable billing that we identified.
"CMS agreed with all of our recommendations and acknowledged that, historically, CMHCs have been vulnerable to fraud, waste and abuse," Rollins added. "CMS also shared information on its efforts to address vulnerabilities in Medicare payments to CMHCs. Specifically, our questionable billing characteristics will be considered in the development of its pilot project focusing on centers in the high-risk States of Florida, Texas and Louisiana."