As a result, the program is vulnerable to exploitation. It should be noted that neither HCFA nor its contractors could accurately tell us what Medicare actually paid the providers in response to these claims. During that same period, the number of Medicare claims climbed 70 percent to 822 million. Several of these initiatives, however, are in their early stages, and it is too soon to assess whether they will, in fact, prevent fraud and abuse in the nursing facilities environment. Conclusion

The multiple ways that providers and suppliers can bill for services to nursing home patients and the lax oversight of this process contribute to the vulnerability of payments for the health care of this population. 4, 1997). Fraud and Abuse: Providers Target Medicare Patients in Nursing Facilities (GAO/HEHS-96-18, Jan. 24, 1996). Fraud and Abuse: Medicare Continues to Be Vulnerable to Exploitation by Unscrupulous Providers (GAO/T-HEHS-96-7, Nov. 2, 1995).
Why GAO Did This Study

GAO discussed the challenges that exist in combatting fraud and abuse in the nursing facility environment.

What GAO Found

GAO noted that: (1) while most providers abide by the rules, some unscrupulous providers of supplies and services have used the nursing facility setting as a target of opportunity; (2) this has occurred for several reasons: (a) the complexities of the reimbursement process invite exploitation; and (b) insufficient control over Medicare claims has reduced the likelihood that inappropriate claims will be denied; (3) GAO is encouraged by a number of recent efforts to combat fraud and abuse, the pending implementation of provisions in the Health Insurance Portability and Accountability Act (HIPPA) and a legislative proposal made by the administration; and (4) while these efforts should make a difference in controlling fraud and abuse in nursing homes, it is too early to tell whether these efforts will be sufficient.