payment police 2.0: how to stop paying bad medicare and medicaid claims

8/6/2019 Payment Police 2.0: How to Stop Paying Bad Medicare and Medicaid Claims

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Payment Police 2.0

How to stop paying bad Medicare and Medicaid claims

Marsha Simon May 2011


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Payment Police 2.0How to stop paying bad Medicare and Medicaid claims

Marsha Simon May 2011

CAPs Doing What Works project promotes government reorm to eciently allocate scarce resources and

achieve greater results or the American people. This project specifcally has three key objectives:

Eliminating or redesigning misguided spending programs and tax expenditures, ocused on priority areas

such as health care, energy, and education Boosting government productivity by streamlining management and strengthening operations in the areas

o human resources, inormation technology, and procurement

Building a oundation or smarter decision-making by enhancing transparency and perormance

measurement and evaluation

This paper is one in a series o reports examining government accountability and eciency.


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Doing What Works Advisory Board

Andres Alonso

CEO, Baltimore Public School System

Yigal Arens

Proessor, USC School o Engineering

Ian Ayres

Proessor, Yale Law School

Gary D. Bass

Executive Director, OMB Watch

Larisa Benson

Washington State Director o Perormance

Audit and Review

Anna Burger

Secretary-Treasurer, SEIU

Jack DangermondPresident, ESRI

Beverly Hall

Superintendent, Atlanta Public Schools

Elaine Kamarck

Lecturer in Public Policy, Harvard University

Sally Katzen

Executive Managing Director, The Podesta Group

Edward Kleinbard

Proessor, USC School o Law

John Koskinen

Non-Executive Chairman, Freddie Mac

Richard Leone

President, The Century Foundation

Ellen Miller

Executive Director, Sunlight Foundation

Claire OConnor

Former Director o Perormance Management,

City o Los Angeles

Tim OReilly

Founder and CEO, OReilly Media

Ali Partovi

Senior Vice President o Business Development,

MySpace

Tony Scott

Chie Inormation Ocer, Microsot

Richard H. Thaler

Proessor, University o Chicago School

o Business

Eric Toder

Fellow, Urban Institute

Margery Austin Turner

Vice President or Research, Urban Institute

Laura D. Tyson

Proessor, University o Caliornia-Berkeley

School o Business

Members of the advisory board do not necessarily share all the views expressed in this document.


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1 Introduction and summary

3 The ABCs of payment integrity

9 Recommendations for reform

13 Conclusion

14 Endnotes

16 About the author and acknowledgements

Contents


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iu ummy | www.mg.

Introduction and summary

educing healh care raud is he rare policy prioriy shared by boh paries in an

increasingly divided Washingon. Jus las summer srong majoriies in he Senae

and House o epresenaives passedwihou a single objeciona Medicare

aniraud provision ha cos hundreds o millions o dollars.1

For good reason. Te ederal governmens own esimaes o Medicare and

Medicaid paymen error raes run as high as 52 percen or cerain medical sup-

plies.2 Te Governmen Accounabiliy Oce has declared Medicare, he govern-men healh insurance program or reirees, a high-risk or improper paymens

and raud every year since 1990. Medicaid, he governmen healh insurance

program or he poor, joined he GAOs high-risk lis in 2003.3

In 2010, an esimaed oal o $70.4 billion was made in improper paymens or

Medicare and Medicaid healh services. Tis oal includes $34.3 billion or radi-

ional Medicare ee-or-service (a 10.5 percen paymen error rae), $22.5 billion

or Medicaid (a 9.4 percen paymen error rae) and 13.6 percen or Medicare

managed care alernaive o ee-or-service (a 14.1 percen paymen error rae).4

Billions o axpayer dollars are clearly a sake.

Billions o dollars have also been spen o reduce improper paymens. Te ederal

governmen has spen nearly $1 billion every year since 1997 on eors o lower

he Medicare paymen error rae. Medicaid has likewise invesed ens o millions

o dollars in so-called paymen inegriy aciviies.

And ye he governmen makes virually no eor o undersand wha paymen

inegriy approaches work bes, or wha kinds o errors are mos likely o harmpoor, elderly, and severely disabled beneciaries. Indeed, he Obama adminisra-

ion has dispached is Medicare raud-prevenion ask orces exclusively o areas

wih high concenraion o low-income and minoriy populaions, according

o oni Miles, a proessor and exper on healh dispariies a he Universiy o

Louisvilles medical school.5,6


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2 c am pg | pym p 2.0: hw yg M M m

Tis paper explains how he design o he Medicare and Medicaid programs

encourages improper paymens and impedes deecion and recoupmen o hese

paymens. I oulines a research and policy agenda o address hese shorcomings.

Specically, we propose ha he governmen:

Develop an evidence-based research agenda o deermine which approaches oreducing paymen error work and which do no, and how o bes proec bene-

ciaries rom paymen error Inves in beter-inegraed daabases o medical claims arge paymen review eors on high-cos paiens enrolled in boh Medicare

and Medicaid, and on high-risk providersAccelerae he deploymen o he so-called Medi-Medi paymen inegriy

program ha examines paterns o improper paymens no deecable by

audiing jus Medicare or Medicaid alone Immediaely implemen new screening requiremens under he Aordable Care

Ac using independen conracors ocused solely on ha ask Eliminae conics o ineres beween conracors who enroll providers, pay

heir Medicare claims, review he claims or errors, and handle appeals o

hese decisions Check providers and beneciaries agains sae and ederal deah records and

oher public daabases equire Medicare claim paymen conracors o reimburse he governmen or

errors hey makeVigorously deend paymen inegriy conracors in appeals o adminisraive

law judges

Tese recommendaions will ensure ha he Obama adminisraions ramp up

o hundreds o millions o addiional dollars or paymen inegriy provides he

greaes reurn on he axpayers invesmen.7


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t abc ym gy | www.mg.

The ABCs of payment integrity

MACs, RACs, and ZPICs

Te Medicare program is a $500 billion a year enerprise, largely adminisered

by privae companies collecively reerred o as conracors. Tese conrac-

ors carry ou mos o he programs operaions, including enrolling docors and

equipmen suppliers; reviewing, paying and audiing claims; and adjudicaing

complains. Mos o he ederal conracor dollars go o or-pro subsidiaries o

Blue Cross Blue Shield insurance plans.

Who oversees Medicare providers o saeguard agains paymen errors? Te con-

venional wisdom is ha specialis companies known as zone paymen inegriy

conracors man he ron lines agains raudulen and misaken paymens. In

ac, he companies ha receive he lions share o he more han $720 million

in aniraud unds doled ou each year are he same conracors responsible or

screening and enrolling Medicare healh providers and suppliers, and paying

heir claims or medical services.8

Tese Medicare adminisraive conracors, or MACs, acually commi he

errors measured by he ocial paymen-error esimae, he Comprehensive

Error ae esing program. MACs pay he roughly 1 billion annual claims

generaed by more han 600,000 physicians, hospials, and oher healh care

providers on behal o he 41 million Medicare beneciaries.9 Te reason MACs

ge paymen inegriy money is because hey are responsible or ensuring ha

claims are legiimae beore hey pay hem. Bu MACs, pay no penalies or he

billions o dollars in misaken paymens, unlike similar conracors ha pay he

medical claims o Deparmen o Deense employees.

Afer MACs pay claims, an alphabe soup o oher conracorsPSCs, ZPICs,

MEDICs, and RCsreview claims or raud and error, and reer suspicious

cases o he governmen or invesigaion, enorcemen, and paymen recovery.


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Mos o hese oher conracors are paid on a ee basis. Te RCs, or recovery

audi conracors, however, are paid on a bouny huner scheme, collecing an

average o 11 percen o he erroneous claims hey help ideniy and recover.10

Problems with Medicare and Medicaid payment integrity efforts

Medicare and Medicaid claims paymen sysems are hemselves raugh wih

problems, saring wih widespread conaion o raud wih error. Here is a

shorlis o problems:

Misrepresentation of data

Te Whie House and members o Congress rom boh paries consanly conae

paymen raud and paymen error. For example, he Comprehensive Error aeesing program, which esimaes he prevalence o paymen error, is ofen cied

as a measure o Medicare raud aloneeven hough mos errors are prevenable

billing misakes. Te CE program, which is a saisical exercise, is ofen con-

used wih aciviies o ideniy raudulen billing.

For example, Sen. Charles Grassley (-IA) las monh described CE as cenral

o ensuring ha Medicare and Medicaid dollars are proeced rom raud, wase,

and abuse.11 In ac, because he CE relies on reviewing a random sample o

claims, i canno deec paterns o raudulen billing.

Compounding he conusion, on Klein, a ormer Democraic congressman rom

Florida conaed during a recen House hearing all healh care raud in he Unied

Saes wih Medicare raud:

Its deplorable to think that there are people out there preying on our seniors, but

as everyone here knows, its true. Some estimates say that Medicare faud totals

$60 billion a year. Tats money taken out o the system to line the pockets o

criminals and thieves.12

Kleins commen underscores anoher common conusion beween Medicare and

Medicaid-specic raud and healh care raud in general.


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Insufficient oversight of payment integrity funds

Mos o he unding ha goes o paymen inegriy is no subjec o annual appro-

priaions review, has no sunse dae, and is hereore subjec o no review by he

auhorizing or appropriaions commitees. (See he appendix or a able o he

hisory o paymen inegriy appropriaions)

Tis lack o oversigh has resuled, in 2009, in nearly hree-quarers o he unding

being awarded o conracors ha carry ou a range o aciviies, including paying

claims, raher han hose asked solely wih ideniying and prevening paymen

errors. Beore Congress can properly oversee he ederal governmens paymen

inegriy eors, he appropriaions commitees mus begin, a a minimum, o

annually review all o he unding.

Multiple, uncoordinated Medicare and Medicaid databases

Boh Medicare and Medicaid employ muliple, uncoordinaed daabases

ha are a ragmened pachwork according o a recen CMS repor on

modernizing is sysems.13

Medicare Par B employs 30 dieren, unsynchronized daabases no including

he managed care and drug componens o he program.14 For example, physi-

cians and hospial claims daabases are enirely separae. So a MAC canno

easily deermine ha a docors visi and a hospial say or wo enirely dieren

diagnoses bear urher scruiny. No surprisingly he ZPICs mainain heir own,

unique daabases.

CMS uses dieren daa sysems o pay saes he ederal share o Medicaid medi-

cal claims, collec inormaion on beneciaries and providers, and monior he

accuracy o paymen claims and he qualiy o services. Tere are wo sysems jus

o collec daa on managed care program characerisics.15

Conflicts of interest

Te vas majoriy o he paymen inegriy unding has gone o he MACs ha

pay Medicare claims. Te only review o he Medicare paymen inegriy unds,

carried ou by he Whie Houses Oce o Managemen and Budge in 2005,


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ound ha over 90 percen o he unds wen o he MACs.16 And many o hese

conracs unded wih Medicare paymen inegriy unds violae every ederal

deniion o conic o ineres. For insance, some o hese conracors are asked

simulaneously wih:

Screening and enrolling providers and suppliers eviewing and paying claimsAudiing claims or errors and raud Wriing sofware o screen claims eviewing heir own claims denials

Consider or example riCenurion, LLC, a paymen saeguard conracor joinly

owned by hree conracors serving as MACs: railblazers Healh Enerprises, LLC;

Palmeto, GBA; and Firs Coas Service Opions. Tese hree conracors are in

urn owned by large Blue Cross and Blue Shield insurance plans. Anoher example

is Blue Cross Blue Shield o Alabama, which serves as a paren company o CahabaGBA and Cahaba Saeguard Services. Cahaba GBA serves as he Medicare adminis-

raive conracor in Alabama and Georgia, while Cahaba Saeguard Services simul-

aneously serves as a Program Saeguard Conracor in hose wo saes.17

Insufficient attention to the Medicare beneficiaries and providers most at

risk for improper payments

Te low-income seniors who qualiy or boh Medicare and Medicaid are he big-

ges users o program resources. Te Ceners or Medicare and Medicaid Services

has recognized his by creaing he Medi-Medi program ha audis claims on

behal o dual eligibles o ideniy problemssuch as billing boh programs or

he same serviceha would no be deeced by examining each program sepa-

raely.18 Te program, however, has no grown beyond 10 saes (and has recenly

shrunk o jus eigh in 2010).

Insufficient attention to providers most prone to errors

Tere is also a ailure o ocus on he highes risk providers wih he highes error

raes, such as medical equipmen companies ha supply hings like wheel chairs.

Te Healh and Human Services inspecor general recenly urged ha MACs

review hese claims more closely.19


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Insufficient attention to managed care plans and their marketing practices

Te governmens paymen inegriy eors are ocused almos exclusively on

Medicare ee-or-service plans even hough beneciaries are increasingly in man-

aged care plans. Enrollmen in managed care plans more han doubled beween

2005 and 2009, rom 4.9 million people o 10.9 million peopleor 24 perceno all Medicare beneciaries.20 Te managed care plans are also ofen operaed by

Blue Cross Blue Shield members and oher large healh insurance companies such

as Unied Healh Group. Alhough he governmens risk is limied when bene-

ciaries choose o enroll in a managed care plan, he cusomers risk o being sold a

plan ha does no mee her needs by unscrupulous agens and brokers is no.21

Insufficient attention to prescription drug errors

Tere is litle governmen scruiny o drug companies and o he more han $80billion paid by he ederal governmen annually or prescripion drugs.22 Te govern-

men has no even atemped o compare drug prices repored by pharmaceuical

companies o he Medicaid discoun program, o ederally-unded public healh

clinics, and o he drug purchase program run by he Deparmen o Veerans Aairs.

Perhaps members o he pharmaceuical lobby are responsible or he bigges wase

o he axpayers dollars, and no he so-called phanom pharmacies ha Grassley

claims successully billed millions o dollars o Medicare.23 Given he hisoric $2.3

billion setlemen beween he Jusice Deparmen and Pzer or raudulen marke-

ing in 2009, more scruiny o prescripion drugs is cerainly warraned.

Insufficient attention to Medicaid payment errors

Tere is an imbalance beween he billions spen on Medicare inegriy and he

ens o millions on he Medicaid program. Saes ha manage Medicaid services

have ailed o underake oversigh by hemselves. Tere is litle reason o expec

hey will sep up enorcemen now. In addiion o heir curren scal disress,

saes are required o repay he ederal share (a leas 50 percen) o any paymen

errors idenied, even i he money is never colleced, creaing perverse incen-ives or inacion.24 Moreover, Medicaid beneciariesmosly poor children,

heir mohers, and he elderly poorare especially vulnerable o raudulen and

unnecessary services.


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Daa rom radiology bene managers, or example, reveals overuse o advanced

imaging on young children and excessive sonograms on pregnan women wih

uncomplicaed pregnancies. Daa on over-use o sonograms rom 2007 and 2008

shows ha very low income Medicaid beneciaries are signicanly more likely o

receive excess services (almos one in six) han low-income beneciaries (slighly

more han one in en).25

In addiion, specialy drug managemen companies haveidenied ens o millions o dollars paid o drug companies or human growh

hormone injecions ino poor children paid or by he Medicaid program.

Botom line: Medicare and Medicaid paymen inegriy eors need o be cleaned

up and realigned. Our ocus should be on errors ha hreaen he long-erm

healh o paiens, such as abusive use o expensive, advanced imaging services

ha endanger seniors and childrens healh.

We nex propose a research agenda ha will ensure paymen inegriy dollars are

unneled oward approaches ha have been proven o work.


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rmm m | www.mg.

Recommendations for reform

Te Obama adminisraion has righly emphasized evidence-based decision mak-

ing in designing is healh care policies. Tis sound approach is applied o opics as

diverse as clinical pracice and paymen policybu no o eors o reduce pay-

men error in he Medicare and Medicaid programs. As he General Accouning

Oce repored his year, paymen inegriy eors by conracors did no ocus

on error-prone providers or review and correcive acion.26

Develop an evidence-based research agenda to protect

beneficiaries from payment error

Te adminisraion should develop a research eor o deermine:

Which paymen inegriy approaches reduce errors and which do no Wheher srucural problems in Medicare or Medicaid encourage raud and pay-

men error, and how o correc hem

More research is also needed o ideniy daa problems in ederal daabases

such as he Social Securiy deah index and he reason or he long delay o he

Inegraed Daa eposiory o Medicare claims, a cenralized governmen source

o Medicare and Medicaid wase, raud, and abuse aciviies.

And we mus examine he impac o Medicare and Medicaid raud on low-income

beneciaries. As oni Miles asks: Is here evidence ha medical raud has he

poenial o cause poor oucomes or specic condiions?27 Te governmen

should sar by unding an epidemiological sudy examining he successully lii-

gaed $1.4 billion Eli Lilly Zyprexa and $301 million Pzer Geodon whisleblowercases o deermine wheher Medicare and Medicaid beneciaries were harmed by

he o-label use o powerul anipsychoic drugs.28,29


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Refocus payment integrity policies now

While i conducs his imporan research program he ederal governmen should

also immediaely reocus is paymen inegriy policies along he ollowing lines:

Integrate databases of medical claims

We need signican well-managed daabase improvemens in boh he Medicare

and Medicaid sysems. Medicare provider and beneciary daabases mus be

inegraed. Meanwhile, he long-awaied single claims daabase is sill no online,

and Medicaid beneciary and provider daa is held by each sae wih is own

uniquely ormated recipien and provider les.30 No uniorm aniraud or pay-

men error reducion eor, or even an accurae accouning o he error rae, can

succeed unil hese sysems are modernized and inegraed.

Collect payment error data on dual eligibles

Te ederal governmen should repor o sae Medicaid programs inormaion on

Medicare errors aecing so-called dual eligibles, or low-income seniors enrolled

in boh he Medicare and Medicaid programs. Such errors have been idenied by

paymen saeguard conracors, bu Medicaids share has never been colleced. Te

approximaely nine million dual eligibles comprise only 21 percen o Medicare

enrollees bu accoun or 36 percen o Medicare spending.31 Similarly, in he

Medicaid Program, dual eligibles comprise 15 percen o he Medicaid populaion

bu accoun or 39 percen o Medicaid spending.32 Because i is more expensive o

care or, he dual-eligible populaion is paricularly vulnerable o paymen errors.

Accelerate the Medi-Medi payment integrity program

Te ederal governmen should more quickly deploy he so-called Medi-Medi

paymen inegriy program o allow saes o cooperaively review claims o dual

eligibles. Cash-poor saes should ge ederal unding o allow hem o be aciveparners in his program. Surely ocusing on he mos expensive and mos vulner-

able beneciaries is as appropriae as he adminisraions curren use o Medicare

raud srike orces in poor communiies.


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rmm m | www.mg.

Immediately implement provider-screening requirements in health reform law

Te ederal governmen should immediaely implemen he rigorous screening

and re-screening o Medicare and Medicaid providers as required under he new

healh reorm law. Te screening eor should ocus on ideniying providers

who have los one sae licensebecause o criminal or licensure reasons, orexampleand hopped o anoher sae. A 2006 Medicare demonsraion o

screening echnology, or example, idenied housands o providers who were

conviced sex oenders.

Eliminate conflicts of interest

Te governmen should no allow he same conracors o screen and enroll ben-

eciaries, and also review heir claims. Te Obama adminisraion is now begin-

ning o rebid conicing MAC conracs, so he ime is ripe o creae a new classo ruly independen conracors who will review providers and suppliers beore

hey ever submi a single claim.

Check beneficiaries and providers against death records and other

public databases

Te governmen should crosscheck Medicare Par C and Par D enrollees agains

Social Securiy and local deah records o ensure ha premiums are paid only or

living beneciaries. All Medicare claims should also be mached agains bene-

ciary and provider deah records.

Previous eors o validae Medicare physician-idenicaion numbers exposed

paymens o raudulen providers who used he Medicare ideniers o deceased

docors. A Senae saer uncovered $76.6 million in Medicare paymens o deceased

docors ve years afer CMS hired a eam o conracors including he AMA o

creae a regisry o dead physicians.33 More recenly, he ederal healh deparmens

inspecor general ound ha CMS and is conracors are sill ailing o ideniy and

recoup all paymens made or services claimed or dead beneciaries.34


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Compare drug prices paid by government programs

Te governmen should build on he healh reorm bills requiremen ha he

HHS inspecor general compare prescripion drug prices paid under Medicare

Par D o hose paid under sae Medicaid programs. Te governmen should

mach he pricing daa among ederal and sae payers o ideniy discrepanciesand ensure he governmen is ruly receiving he lowes prices.35

Make MACs pay for errors

Te governmen should require Medicare adminisraive conracors o reimburse

he Medicare program a percenage o paymens made in error. Ta would align

he Medicare paymen inegriy sysem wih he Deense Deparmens healh

care program, riCare, in which conracors pay nes calculaed rom paymen

errors discovered in audis.

Aggressively defend payment error findings

As o June 2010, more han wo-hirds o improper paymen ndings were

reversed i hey reached he nal adminisraive law judge appeals level.36 Paymen

inegriy conracors are no paries o he appeals proceedings, and canno cross-

examine winesses or presen evidence in he hearings. Is up o he governmen,

hereore, o vigorously deend is paymen inegriy conracors when hey

discover errors.


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Conclusion

Te Obama adminisraion should be commended or beginning o push or more

rigorous screening o high-risk Medicare suppliers, bu i is sill neglecing sys-

emic problems in he operaion o he claims paymen sysem.37 Te adminisra-

ion is also overselling is new Medicare claims daabase and sofware analyics.

As he long-delayed Inegraed Daa eposiory iniiaive shows, is unclear when

here will be a single, workable inegraed daabase o Medicare claims. And he pre-

dicive analyics o ideniy high-risk providers claims beore hey are paid is jusbeing piloed now. Tese daabases are no ready or prime ime, much less ready o

provide he real ime access o daa ha adminisraion winesses have oued.

Moreover, Medicare Inegriy Program unds need o be re-deployed o ocus on

high-risk providers and suppliers reques or paymens. Te adminisraion is

again moving in his direcion bu has a long way o go beore hey can say hey

have changed he way he MACs perorm he axpayers business. Te recen

error rae, jus released (bu wihou supporing deail), was oued by he Whie

House as proving he value o heir paymen inegriy campaign. Bu when over

1 in 10 paymens are in error a a cos o $34.3 billion, how can he adminisraion

deend he MACs perormance?38

Fighing healh care raud and error makes good scal and poliical sense bu poli-

cymakers mus x he srucural aws in he curren claims paymen sysem. As

Sen. om Harkin (D-IA), now chair o wo key healh policy commitees, has long

argued: I hese healh programs are no well run, Congress canno successully

persuade voers o he need o spend hundreds o billions o dollars on Medicare

and Medicaid. Te Obama adminisraion can do beter.


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Endnotes

1 Small Business Jobs and Credit Act o 2010 , pu lw 111-240, 124s. 2599 (2010).

2 U.s. dm h hum sv, c M& M sv, im M FFs pym r:nvm 2009 (2009). s du M equm mym .

3 U.s. Gvm auy o, hg r s: a U(2011).

4 U.s. dm h hum sv, c M& M sv, FY 2010 agy F r (2011). Fgu u M p d ug gm c- h iu pgm. s: hg e pgm, v

://www.ymuy.gv/g-y-gm .

5 t p. M, im rm U.s. h c M h d, Public Policy & Aging Report19 (4) (2010): 15-17.

6 U s dm h & hum sv,ayG h hhs sy su au nw i-gy h c Fu pv em a tm,p , My 20, 2009.

7 o Mgm bug, dm h hum sv FY 2011 bug em (2010).

8 Health Insurance and Portability and Accountability Act o 1996, pulw 104-191. 110 s.1996 (1996).

9 M pym avy cmm, r cg:M pym py (2010).

10 Medicare Prescription Drug, Improvement, and Modernization Act o2003, pu lw 108-173, 117 s 2066 (2003); Tax Relie and HealthCare Act o 2006, pu lw 109-432, 120 s. 2922 (2006).

11 U s s cmm F,Gy W iy Fu, W, au, p r, dm 17, 2009.

12 r k, tmy b egy cmm summ- h hg o cug W, Fu, a au i M- a M h.r. 5044, M Fu em pv a, sm 22, 2010.

13 c M M sv it Mz p-gm, Mzg cMs cmu d sym suimvm c dvy (2010).

14 i.

15 i.

16 o Mgm bug, M igy pgmam, (2009).

17 s cmm F, s cmm hm suy Gvm a summ F F Mgm cg ovg, M- c p c i (2011).

18 U.s. dm h hum sv o iG, du M M hm h pym:M su tu sv (Wg, dc, 2008).

19 U.s. dm h hum sv o iG, rvw M pym s du M- equm w kX M f c Y 2006(2010).

20 M pym avy cmm, r cg: M- pym py (2010).

21 U.s. Gvm auy o, M avg: cMsa bf a y i Mg u lm s iu (2009).

22 U.s. Gvm auy o, p dug: ovvw a c p dug sg Fpgm(2009); M pym avy cmm,r cg: im cg M pym p bdug (2007).

23 U s s cmm F,Gy W iy Fu, W, au..

24 t n a s bug o, F suvy s, F 2010: a U s F c (2010).

25 n imgg a, Uu Uu d mM Uz rvw (2007-2008).

26 U.s. dm h hum sv o iG, c M & M sv U MF--sv e r d iy Fu e-ppv (2010).

27 M, im rm U.s. h c M hd..

28 U s dm Ju,pmu cmye ly py r $1.415 b o-l dug Mg,p , Juy 15, 2009.

29 U s dm Ju,pmu cmypfz, i. py $301 M o -l dug Mg, p, sm 2, 2009.

30 c M M sv it Mz p-gm, Mzg cMs cmu d sym suimvm c dvy.

31 k Fmy Fu pgm M py, t r M p duy eg M M(2011).

32 i.

33 pm summ ivg, M Vu-: pym cm t d d (2008).

34 U.s. dm h hum sv o iG, rvw M p a b sv b w d sv a bf d (2010).
http://www.paymentaccuracy.gov/high-priority-programshttp://www.paymentaccuracy.gov/high-priority-programs


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35 Patient Protection and Afordable Care Act, pu lw 111-148, 124s. 477 (2010).

36 dv s, cMs M rvw Mgc (Ju 2010).

37 c M & M sv, M, M, c h iu pgm; a sgrqum, a F, tmy em M,pym su cm p pv su (2010).

38 U.s. dm h hum sv, FY 2010 agyF r (2010).


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About the author

Dr. Marsha Simon is an exper in legislaive sraegy, nonpro managemen, and

public policy research, wih over 20 years o experience, including nearly a decade

working or he Unied Saes Senae. She served as senior commitee sa o Sens.

Edward M. Kennedy (D-MA), om Harkin (D-IA), and ober C. Byrd (D-WV),advising hem on public healh and welare policy, as well as on he budge and

appropriaions processes. Tese sa posiions included minoriy sa direcor

or he Senae Appropriaions Commitees Subcommitee on Labor, Healh, and

Human Services, Educaion and elaed Agencies or Sen. om Harkin; and chie

policy advisor or Budge and Healh Policy or he Senae Commitee on Healh,

Educaion Labor, and Pensions or Sen. Edward Kennedy. Sen. Harkin is now

chair o he Appropriaions Subcommitee, as well as o he Healh, Educaion,

Labor, and Pensions Commitee ha is responsible or public healh measures,

including biomedical research and ood and drug law.

In addiion o her experience working or he U.S. Senae, Dr. Simon has managed

governmen relaions or diverse healh, income securiy, and welare sakehold-

ers, including or he Jeerson Consuling Group, a lobbying and ederal business

developmen rm; he American College o Obserics and Gynecology; and pub-

lic ineres groups, including Families USA, he Food esearch and Acion Cener,

he Housing Assisance Council, and ural America (now he Communiy

ransporaion Associaion o America).

Dr. Simon served on Barack Obamas healh advisory commitee during his

presidenial campaign. She also served as a policy advisor on Gov. Howard Deans

campaign and drafed his long-erm care plaorm. She was also a member o he

Clinon adminisraions Naional ask orce on Healh Care eorm.

Dr. Simon earned a Ph.D. and an M.S. in poliical science rom he Massachusets

Insiue o echnology. In addiion o her work a Simon & Co., Dr. Simon

is also an adjunc proessor in he Deparmen o Healh Policy a George

Washingon Universiy.


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au u wgm | www.mg.

Acknowledgements

Te auhor would like o hank he ockeeller Foundaion or is generous sup-

por. Te auhor would also like o acknowledge Judy Feder who proposed ha

I wrie his paper or he series and provided her good oces wih CAP and HHS.

In addiion, Jamison Scot, Karen Lae and Gadi Decher provided exper researchand ediorial assisance.


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The Center or American Progress is a nonpartisan research and educational institute

dedicated to promoting a strong, just and ree America that ensures opportunity

or all. We believe that Americans are bound together by a common commitment to

these values and we aspire to ensure that our national policies relect these values.

We work to ind progressive and pragmatic solutions to signiicant domestic and

international problems and develop policy proposals that oster a government that

is o the people, by the people, and or the people.

payment police 2.0: how to stop paying bad medicare and medicaid claims

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