HC Reform and HCRS Essay Sample

HC Reform and HCRS


There is a growing concern in the country regarding losses caused due to fraud, waste and abuse of resources and services in the health care system.  According to NHCAA (National Health Care Anti Fraud Association) the losses caused due to health care fraud is an estimate of 60 billion dollars a year  (Robles, 2009 ).

It has become imperative that immediate steps be taken to prevent FWA as   the cost of health care escalates every day.  Various strategies include: increase in the investigation efforts at the grass roots level and implementation of technology to enhance data security and integration

The government of US  has  made a conscious effort  and  has invested  a considerable amount of the taxpayers money  in taking effective steps to prevent  fraud , waste and abuse in the government’s  largest  provider of health care insurance programs : Medicare and Medicaid.

There are several legislations that have been passed to prevent FWA in the health care system and by health care providers and various programs have also been established for this purpose.   CMS,  HHS and other government organisations are dedicated to implementing these programs.


The methodology of collecting data has vastly been electronic, as the sources for data and information regarding the subject is easily available on the internet and as these are primarily government sources the security of the data source is validated.


A review on the performance of the,US  Department of Health and Human Services and CMS in preventing fraud waste and abuse and  whether CMS has been successful in preventing FWA in the health care system.

Centers for Medicare and Medicaid Services

The Centre for Medicare and Medicaid Services oversees the nation’s largest health insurance programs: Medicare and Medicaid, CMS is a part of Health and Human Services department (HHS). In its attempt to safeguard Medicare and Medicaid against fraud waste and abuse, CMS have employed PSC’s (Program safeguard contractors) in an attempt to “Detect and dether Medicare fraud and Abuse” (Hill, 2007).

Review of the CMS Performance in Fraud Waste and Abuse Prevention Efforts

  1.  In an effort to prevent losses caused due to fraud waste and abuse the CMS have made it mandatory that its sponsors  ensure mandatory training of their employees under 42 CFR parts 422.503 and 423.504 and require that:

“Effective training to incorporate measures to detect, prevent and correct fraud waste and abuse. Provide training to all first tiers, downstream and related entities. Produce attestations of the training and retain copies of training logs” (New West Health Services, 2009).

  1.  Implementation of the ICD-10 and Version 5010-ICD-10 coding systems which is much more effective than ICD 9 and CMS is hopeful that it will be easier to detect if a claim was appropriately billed and its increased specificity will make it easier to prevent fraud, abuse and waste in the system. (Justification of Estimates for Appropriations Committees, 2009)
  2. In order to prevent fraud  CMS also requires  that  Medicare contractors  improve their  statutory  level of bills /claims processing  timeliness performance which may improve  their ability to  fraud and abuse in the system. (Justification of Estimates for Appropriations Committees,2009, p.19)
  3. The deficit reduction act of 2005 increases the responsibility and obligation of CMS to prevent fraud abuse and waste in the system and to conduct audit checks by auditors on health care providers on over payments   and to also employ contractors to provide education on FWA policies.  CMS has also implemented computer algorithms for analysis of state Medicaid claims data. (Justification of Estimates for Appropriations Committees, 2009, p.57)
  4. In accordance with the improper payments information act of 2002, CMS intends to “Strengthen Medicare program integrity efforts to reduce improper payments and reduce fraud and abuse” (Justification of Estimates for Appropriations Committees, 2009, p. 77)

Quality Improvement Organizations (QIO)

QIO’s are contractors who ensure that medicare“pays for only medically necessary services and investigates beneficiary complaints on the quality of services”. (Hill, 2007)

They are not effectively charged with the responsibility of preventing fraud, abuse and waste like the PSC’s   but they are mainly concerned with referring benefit integrity issues to PSC (Sageguard Services Inc, 2009). 

According to the Health Care Associations of New York State, a few QIOs of note are:

  1. CMS Quality of Care information
  2. IPRO
  3. Institute for safe medication practices
  4. Medical Outcomes Trust
  5. Mederrors.com
  6. National Association of Health Data Organizations.( Health Care Associations of New York State, 2009).

CMS Performance Review

  1.  “There has been a marked increase in the performance of  CMS and HHS in preventing fraud waste and abuse in  the country”, According to  William Corr , the government has  been able to  save 4 billion dollars in receivables, in comparison to  3.2 billion from the OIG investigative  receivables in 2008” (Corr, 2009).
  2. PSCs were established in all areas of USA to decrease FWA among various providers and supplier types.  “The PSC performs data analysis  to identify various problem areas, investigate potential fraud , develop fraud cases for referral to law enforcement agencies and to coordinate Medicare fraud ,waste and abuse efforts , waste and abuse efforts  with CMS’ internal and external partners ” (Hill, 2007).

The Health Care Fraud and Abuse Control Program (HCFAC) program    has been able to return” 13.1 billion dollars to the Medicare Trust Fund”. (Corr, 2009).

  1. The deficit reduction act of 2005 has been instrumental in the creation the Medicaid integrity program and the Medi-Medi data match point pilot program   that have been able to refer “ 30 cases to law enforcement agencies, 27 million in overpayments which were referred to collections and 7 million dollars were saved in erroneous payments” (Corr, 2009). 
  2. CMS is in the process of building an Integrated data depository  which will change the  manner in which application and claims will be reviewed , if there are a high volume of billings or if there are aberrations in claims data  instead of sifting through colossal amount of paperwork  CMS will be able to identify the fraud immediately (Corr, 2009).


Health Care Resolutions Services Inc is a leading health care consulting firm and offers various programs for auditing medical records, identifying fraud and waste and maintaining integrity in the medical organizations that they work with; The Department of Defense is one of their major clients among other institutions of note.

One of the key expertise of HCRS Inc  lies in their ability to identify fraud waste and abuse, in accordance to the stipulations identified by the CMS/JCAHO/DoD/VA in their client organizations (www. hcrs-inc.com).

In adherence  with the  CMS efforts to sustain  data security and  data integration efforts,  HCRS are able to “conduct  clinical coding reviews,   collect, standardize and validate coding practices  and also provide  reviewer provider activities and audit claims , identifying overpayments and training requirements, reimbursements requirements and recovery  ”(Program Integrity, 2009)

They are also able to conduct audit that ensure the data integrity and consistent  and have also developed a software tool called  the ecoder that enhances the ability of auditors to document their coding in real time and helps them in  producing individual case summaries  provider summaries  and overall  audit statistics. ”(Program Integrity, 2009)

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HCRS also provide training services for their clients in compliance with the HIPAA    and health information technology for their end users. (Health Information Technology and Management Services, 2009)


Organizations and criminals who make fraudulent claims cases are  experts in their fields and the government have  to use the latest technologies and  specialised services  to ensure  the prevention FWA.  

The finances saved by the government by preventing frauds and through recoveries, can be used in implementing programs for the improvement of health care services and benefits for the citizens of USA.

FWA prevention has to be a collaborative effort between the private, public and government sector to be effective. Compliance with CMS, HHS and DOJ to prevent fraud may seem tedious at the individual level but should meticulously complied with,   as the benefits are reaped by the entire community.

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