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Department of Health and Human Services

Office of Inspector General -- AUDIT

"Review of Unlicensed Providers in Puerto Rico," (A-02-02-01014)

September 24, 2003

Complete Text of Report is available in PDF format (523 kb). Copies can also be obtained by contacting the Office of Public Affairs at 202-619-1343.


The objective of this audit was to determine whether unlicensed providers in Puerto Rico were submitting claims and being paid for services rendered to Medicare beneficiaries and whether these claims indicated cause for concerns relating to quality of care or program abuse.  Medicare laws and regulations require that providers must comply with Federal, State and local licensure and certification requirements.  We found that the Medicare program paid $3,607,820 from 1998 through 2001 to 63 providers who were not eligible to claim payment for Medicare services. We also found that the Medicare carrier and the OIG had increased their oversight of 24 of the 63 providers because of beneficiary complaints and aberrant billing and utilization patterns.  We recommended that the carrier coordinate efforts with the Centers for Medicare and Medicaid Services Regional Office to monitor provider enrollments in order to protect the Medicare beneficiaries and the Medicare program, resolve the payments issued to ineligible providers and preclude any such payments in the future, and improve communications with local licensing agencies.  The carrier generally concurred with the recommendations but indicated that they had obtained additional evidence from some of the providers which could reduce the payments attributed to ineligible providers.