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Transcript for the audio podcast:
Unlawfully Present and Incarcerated Medicare Patients

From the Office of Inspector General of Department of Health and Human Services

[Patrick Cogley] I'm Patrick Cogley, Regional Inspector General for Audit Services in Kansas City. And, today, I'm speaking with Chris Bresette. He's an audit manager also located in Kansas City. Chris, your audit team recently completed two audits that identified over $120 million of improper payments. What were the subject matters of these reports?

[Chris Bresette] We audited Medicare payments that were made for patients who were either not lawfully present in the United States or for patients who were incarcerated.

[Patrick Cogley] Okay could you tell me exactly what is an unlawfully present Medicare patient?

[Chris Bresette] A lawfully present Medicare patient is an immigrant living in the United States legally. Unlawful presence occurs when a non-U.S. citizen remains in the United States longer than the time authorized by U.S Immigration Agencies.

[Patrick Cogley] And can you provide more information regarding incarcerated patients?

[Chris Bresette] Sure. They are people who are under arrest, imprisoned, reside in a halfway house, or required to live under home detention.

[Patrick Cogley] I understand that Medicare does not make payments for unlawfully present patients and generally does not pay for incarcerated patients. How does the Centers for Medicare and Medicaid Services, or CMS, identify these people?

[Chris Bresette] Actually, the Social Security Administration, or SSA, works with prison systems, other Federal agencies, and uses data systems to identify both unlawfully present and incarcerated patients. The SSA then transmits the names of these people to CMS via a computer link.

[Patrick Cogley] How well does the data transmission between CMS and SSA work?

[Chris Bresette] If CMS receives the names from SSA before a patient receives a service... CMS effectively stops the payments.

[Patrick Cogley] What if CMS receives the information after the claim was processed?

[Chris Bresette] Our audit found that CMS does not always receive this information promptly. In these instances, the claims are paid. CMS did not have policies and procedures to go back and detect and recover the money.

[Patrick Cogley] How did the lack of policies and procedures impact the Medicare program, in terms of improper payments?

[Chris Bresette] From 2009 - 2011, we identified $92 million of payments that Medicare contractors made to health care providers for unlawfully present patients. We also found $34 million of improper payments for incarcerated patients.

[Patrick Cogley] Based on your analysis of these errors, what did you recommend to CMS and how did they respond?

[Chris Bresette] We recommended that CMS direct the Medicare contractors to recoup all of the improper payments. CMS agreed, but said that it would have to consider the cost benefit of getting the money back. We agreed with CMS. CMS also told us that it has already started recovering the improper payments.

[Patrick Cogley] Your audit period ended in 2011. What about claims paid during 2012?

[Chris Bresette] We recommended that CMS identify and recoup any improper payment made after our audit period. We also recommended that CMS implement policies and procedures to detect and recoup these overpayments. CMS agreed with both of these recommendations for both reports.

[Patrick Cogley] What you have described so far applied to both reports. However, there were two recommendations that were unique to the incarcerated report. Could you describe them?

[Chris Bresette] Although the data exchange between agencies works pretty well, the incarceration information does not always come to CMS promptly. We recommended that CMS work with other companies, as well as the Social Security Administration, to improve the timeliness of receiving this information. CMS agreed.

[Patrick Cogley] Earlier you said that Medicare generally does not pay for incarcerated patients. Could you talk about when Medicare can make these payments?

[Chris Bresette] Medicare will pay health care providers if the incarcerated patient is located in a place where State or local law requires the individuals to repay the cost of the services. CMS required the providers to use what's called an "exception code" to indicate that the claims were allowable. But... we found that Medicare contractors and providers had their own varying policies when using this code. We recommended that CMS standardize the use of this code. Although CMS did not agree with this recommendation, it asked for additional information, which we provided to CMS before we issued the final report.

[Patrick Cogley] Thank you, Chris, for sharing this important work.

[Chris Bresette] Thank you.


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