OIG Report on Medicare Payments to Unlawful Beneficiaries

The Office of Inspector General performed a study to determine if CMS data systems were adequate to prevent Medicare payments for unlawfully present beneficiaries. The study found that Medicare payments totaling $91,620,548 were made for 2,575 unlawfully present beneficiaries during FY 2009 to 2011.  It found that CMS did not have policies and procedures to review unlawful presence information on a post payment basis that would have detected improper payment that the prepayment edit could not prevent.  Consequently, CMS did not notify the Medicare contractors to recoup any of the $91,620,548 in improper payments. 

CMS released a MLN Matter Number: MM8009 on November 1, 2012 to perform new Informational Unsolicited Response (IUR) process to identify previously paid claims for services furnished to Medicare beneficiaries classified as “Unlawfully Present” in the United States.  The IUR process shall be initiated when there is an automatic update to the beneficiary’s record in the CWF via an EDB transaction which indicates a change to the beneficiary’s “unlawfully present” start or end date or when there is a manual update to the beneficiary’s record in CWF which indicate a change to the beneficiary’s “unlawfully present” start date or end date.  Upon receiving the IUR Medicare contracts will initiate overpayment recovery procedures to recoup any Medicare Part A and Part B payments.

For more information on OIG Study please utilize the following link.

https://oig.hhs.gov/oas/reports/region7/71201116.pdf

For more information on Future Medicare Learning Network Article please utilize the following link.

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/mm8009.pdf