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Medicare Improperly Paid Millions of Dollars for Unlawfully Present Beneficiaries for 2013 and 2014

The Centers for Medicare & Medicaid Services (CMS) had policies and procedures to ensure that payments were not made for Medicare services rendered to unlawfully present beneficiaries in accordance with Federal requirements, but it did not always follow those policies and procedures. When CMS's data systems indicated that at the time a claim was processed the beneficiary was unlawfully present, CMS had policies and procedures to prevent payment for Medicare services, and CMS followed those procedures.

However, when CMS's data systems did not indicate until after a claim had been processed that a beneficiary was unlawfully present, CMS had policies and procedures to detect and recoup payment for Medicare services, but it did not follow them. Specifically, CMS determined that beneficiaries were liable for these improper payments, but it did not notify Medicare contractors to initiate recoupment activities with those beneficiaries.

CMS officials explained that although CMS has not attempted to collect improper payments from unlawfully present beneficiaries, CMS is reviewing the feasibility of pursuing recoupment from these beneficiaries. In this regard, CMS officials said that CMS's review will identify individuals for whom CMS can direct its contractors to pursue recoupment, including the $9.3 million in improper payments made for Medicare services rendered to 481 unlawfully present beneficiaries in calendar years 2013 and 2014.

We recommended that CMS direct its Medicare contractors, to the maximum extent feasible, to initiate recoupment activities (1) against the 481 unlawfully present beneficiaries on whose behalf Medicare made $9.3 million in improper payments and (2) for improper payments made after our audit period on behalf of any beneficiaries who are detected to be unlawfully present. CMS concurred with our recommendations.

Filed under: Center for Medicare and Medicaid Services