Performance Improvement 2008. Where Were the Highest Fraudulent Claims for Infusion Therapy?


In three South Florida counties, this study identified claims patterns associated with HIV/AIDS infusion therapy––therapy that involved medicines and fluids given through a catheter into a person´s bloodstream––that might have indicated fraudulent or abusive activity. Researchers assessed the effectiveness of past and current efforts to control inappropriate payments to infusion therapy providers. In June 2003, the program safeguard contractor alerted the Centers for Medicare and Medicaid Services (CMS) that providers in Miami-Dade, Broward, and Palm Beach counties were billing aberrantly for infusion therapy services for beneficiaries with HIV/AIDS. Related investigations found that many of the services billed by these providers were not medically necessary or feasible. In May 2004, CMS issued a National Medicare Fraud Alert describing the "infusion therapy scam." By 2005, the three counties accounted for 72 percent of submitted charges for beneficiaries with HIV/AIDS nationwide, though only 8 percent of such beneficiaries lived there. Most of these charges were for drugs used in infusion therapy. Researchers used Medicare Part B National Claims History data from 2006 to analyze beneficiary and provider claims patterns in South Florida. Researchers interviewed staff from CMS and its contractors and reviewed documents related to infusion fraud to assess the efforts to control aberrant billing.

In the last half of 2006, three South Florida counties accounted for half the total amount of infusion therapy provided and 79 percent of the amount for drugs billed nationally for Medicare beneficiaries with HIV/AIDS. Other metropolitan areas exhibited patterns of billing similar to South Florida but to a lesser extent. CMS has had limited success in controlling the aberrant billing practices of South Florida infusion therapy providers. Researchers recommended mandatory site visits to high risk jurisdictions, more time for payment contractors to review payment requests from these areas, and enhanced fraud- and abuse-fighting efforts.

Report Title: Aberrant Billing in South Florida for Beneficiaries with HIV/AIDS,
Agency Sponsor: OS-OIG, Office of Inspector General
Federal Contact: Claire Barnard, 202-205-9523
Performer: Office of Inspector General
PIC ID: 8788

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"PerformanceImprovement2008.pdf" (pdf, 1.29Mb)

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