United States General Accounting Office

GAO Report to the Ranking Minority Member,

Committee on Commerce, House of

Representatives

January 1996 FRAUD AND ABUSE

Providers Target

Medicare Patients in

Nursing Facilities

GAO/HEHS-96-18

GAO United States

General Accounting Office

Washington, D.C. 20548

Health, Education, and

Human Services Division

B-255730 

January 24, 1996

The Honorable John D. Dingell

Ranking Minority Member

Committee on Commerce

House of Representatives

Dear Mr. Dingell:

At recent congressional hearings on efforts to trim billions of dollars from

the rapidly growing Medicare program, we testified on the program’s

vulnerabilities to waste, fraud, and abuse.1

 Among the major weaknesses

is the Health Care Financing Administration’s (HCFA) inadequate array of

controls—both for detecting billing abuses and for ensuring the legitimacy

of providers billing the Medicare program.2

One of your concerns focused on the numerous allegations of fraud and

abuse related to services provided to Medicare patients in nursing

facilities.3

 In 1995, physicians, medical equipment companies, laboratories,

and other providers were reimbursed an estimated $5.5 billion for the

services and supplies they furnished Medicare patients in nursing facilities.

Because some portion of this amount is likely to have been paid

unnecessarily, you asked us to review (1) the nature and extent of fraud

and abuse related to services and supplies provided to nursing facility

patients, (2) the conditions that make the provision of services and

supplies to nursing facility patients an attractive opportunity for

wrongdoers, and (3) options for removing such opportunity.

For this review, we interviewed officials at HCFA, Medicare claims

processors, HHS Office of Inspector General (OIG), and several national

organizations representing the nursing home industry and providers of

services and supplies. We also analyzed documents for ongoing and

recently completed investigations by Medicare claims processors and OIG,

and interviewed investigators working on those cases to identify factors

leading to fraudulent and abusive billing situations. Our work was done

between April 1994 and August 1995 in accordance with generally

1

See Related GAO Products at the end of this report.

2

Within the U.S. Department of Health and Human Services (HHS), HCFA establishes regulations and

policy guidance for the Medicare program.

3

In this report, the term “nursing facility” is used to describe a nursing home that could provide

services ranging from skilled care for patients with complex medical or rehabilitative needs to

custodial care for those patients needing assistance with activities of daily living.

Page 1 GAO/HEHS-96-18 Targeting of Nursing Facility Patients
B-255730 

accepted government auditing standards. Further details of our scope and

methodology are provided in appendix I.

Results in Brief Although most providers are honest and bill appropriately, a wide array of

provider types—including durable medical equipment suppliers,

laboratories, physicians, optometrists, and psychiatrists—have been

involved in the fraudulent or abusive billing of Medicare for services and

supplies furnished to nursing facility patients. The wrongdoing has

generally focused on billing Medicare for unnecessary or undelivered

services, or misrepresenting a service to obtain reimbursement. The

investigations we reviewed probed activities in over 40 states, with many

providers operating in multiple states. Although not quantifiable, the

evidence suggests that such fraud and abusive billing activities are

frequent and widespread.

Several features make Medicare beneficiaries in nursing homes an

attractive target for fraudulent and abusive activity. First, because a

nursing facility locates individual Medicare beneficiaries under one roof,

unscrupulous billers of services can operate their schemes in volume.

Second, in some instances, nursing facilities make patient records

available to outside providers who are not responsible for the direct care

of the patient, contrary to federal regulations which prohibit such

inappropriate access. In such cases, nursing facilities—however

inadvertently—enable exploitative providers to obtain the information on

Medicare beneficiaries that they need to bill Medicare.

Third, under HCFA’s provisions for reimbursement, providers can bill

Medicare directly, without the nursing facility or attending physician

affirming whether the items were necessary or provided as claimed. Nor is

the scrutiny at the claims processor level adequate. Medicare’s automated

systems do not accumulate data that would flag timely indications of

improbably high charges or levels of services. As a result, Medicare claims

processors miss opportunities to avoid paying out large sums

unnecessarily and to track schemes exploiting groups of vulnerable

beneficiaries. Finally, even when Medicare detects abusive billings and

seeks recovery of unwarranted payments, it often receives little repayment

from the wrongdoers who either go out of business or deplete their

resources so that they lack the resources to repay the funds.

Medicare needs to change the way it reimburses for services and supplies

provided to beneficiaries residing in nursing facilities. Because these

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facilities have a primary role in planning their residents’ care, they are in

the best position to monitor the provision of services and supplies.

Although options exist for such involvement of nursing facilities, all

require structural—and therefore long-term—changes. In the meantime,

certain incremental changes would make the nursing facility environment

less hospitable to fraudulent or abusive billing activities. These changes

include instituting penalties at the federal level for the unauthorized

disclosure of patients’ medical records and programming various early

warning controls in Medicare’s claims processing systems to better detect

fraud and abusive billings before claims are paid.

Background As the nation’s largest health care payer, Medicare provides health

insurance coverage to over 36 million elderly and disabled Americans.

Medicare part A covers inpatient care in a hospital or skilled nursing

facility and home health or hospice care. The care in skilled nursing

facilities that part A covers—for which Medicare paid an estimated

$6.6 billion in 1995—is limited to relatively short stays for patients who

need daily skilled care following hospitalization. Most elderly people in

nursing facilities do not qualify for part A coverage.

Medicare part B covers physician services, outpatient hospital services,

durable medical equipment, and various other health services. Although

the vast majority of Medicare patients in nursing facilities do not require

skilled nursing care, they are entitled to the full range of services and

supplies covered by the Medicare part B program when part A does not

pay for the nursing facility services themselves.4

 This care is usually billed

directly to Medicare by the providers who serve these patients. In 1995,

Medicare paid an estimated $5.5 billion for services and supplies furnished

to patients in nursing facilities.

HCFA contracts with insurers, such as Blue Cross and Blue Shield plans,

Aetna, and The Travelers Insurance Company, to process and pay claims

submitted by providers. These contractors—referred to as carriers under

Medicare part B—are responsible for the monitoring and analysis of

claims both before and after payment to ensure that Medicare dollars are

used to pay only reasonable and necessary claims. Carriers’ automated

claims processing systems include computerized controls, or screens, that

screen claims for diagnosis coding errors, billing abuses, and incorrect or

incomplete documentation. Some controls deny or adjust claims payments

automatically without human intervention. Others flag claims for further

4

Stays in nursing facilities are primarily paid by the individual or Medicaid.

Page 3 GAO/HEHS-96-18 Targeting of Nursing Facility Patients
B-255730 

review by carrier personnel if the claims do not conform to payment

criteria or are submitted by a provider under carrier scrutiny.

Nursing facility patients—many of whom are cognitively impaired—rely

on the facility to manage their care needs. Under the nursing home reform

provisions established by the Omnibus Budget Reconciliation Act of 1987,

nursing facilities have a major role in designing plans of care for each of

their patients. The act imposed requirements that nursing facilities provide

those services and activities necessary to attain or maintain the highest

practicable physical, mental, and psychosocial well-being of each resident.

Upon a patient’s admission to a facility, a registered nurse must conduct or

coordinate a comprehensive assessment of medical, nursing, mental, and

psychosocial needs. The facility must then develop a comprehensive plan

of care for the patient that includes measurable objectives and timetables

to meet the patient’s needs identified in the comprehensive assessment.

Each assessment must be reviewed at least every 3 months; any revisions

must be reflected in the corresponding plan of care.

Instances of Wrongful

Billing Suggest

Widespread Activity

Fraudulent and abusive practices by some providers who furnish services

and supplies to nursing facility patients entail billing Medicare for

unnecessary or undelivered services and supplies or misrepresenting a

service or supply item to obtain Medicare reimbursement as the following

examples show:

• A company billed Medicare for heart monitoring services provided to

nursing facility patients. The diagnoses entered on the Medicare claims

forms by the laboratory were false and did not reflect the patients’

condition at the time services were ordered and rendered. Medicare

overpaid this company an estimated $4.3 million.5

• An optometrist filed Medicare claims for services either not medically

necessary or not provided to nursing facility patients from 1991 through

1993. Medicare paid this practitioner over $190,000 for these services.

• A supplier billed Medicare for ostomy, enteral, and surgical dressing

supplies that it had not delivered and forged the attending physicians’

signatures on the certificates of medical necessity using samples of signed

orders found in patients’ files. This case involved about 4,000 fraudulent

claims totaling about $1.5 million.

5

An additional $655,000 approved for payment was withheld by the Medicare claims processing

contractor once the contractor had identified the problem.

Page 4 GAO/HEHS-96-18 Targeting of Nursing Facility Patients
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These fraudulent and abusive activities involve a wide array of provider

types, including ambulance service companies, dentists, medical

equipment suppliers, general practitioners, internists, laboratories,

optometrists, podiatrists, psychiatrists, and psychologists. The actual

extent of the problem cannot be quantified, but the evidence suggests that

it is widespread.6

 Our review of ongoing and completed investigations by

Medicare carriers and HHS OIG included cases encompassing at least 41

states, the District of Columbia, and Puerto Rico. Thirty of the providers in

these cases operated in multiple states as these examples illustrate:

• A supplier currently under investigation for allegedly billing Medicare for

surgical dressing kits and components that were not provided or medically

necessary operates in at least 20 states.

• Another supplier with offices in at least seven states billed Medicare for

incontinence supplies that were inflated in price, not provided, or not

medically necessary.7

• Another company under investigation for inappropriately billing Medicare

for heart monitoring services operates in at least 11 states.

Because data on fraud and abuse have not been accumulated based on

place of service, investigators cannot quantify the extent of Medicare fraud

and abuse involving the provision of services and supplies to nursing

facility patients. Medicare carriers and OIG officials believe, however, that

fraud involving services provided in nursing facilities is significant. In

1994, the Senate Special Committee on Aging reported a considerable

number of cases involving the targeting of nursing facility patients by

industries that supply products and services directly to them.8

 Also in

1994, OIG reported on a completed investigation in which Medicare had

paid over $7.4 million to a billing company (representing 70 nursing

facilities in 7 states) that had billed for surgical dressings supplied to

nursing facility patients who had had no surgery. And in February 1995

testimony before the House Committee on Ways and Means,

Subcommittee on Health, the Inspector General reported that about half of

the $230 million Medicare approved in 1993 nationally for incontinence

6

See app. II for examples of closed fraud investigations.

7

The controller of the parent company recently pled guilty to submitting more than $4.4 million of false

and fraudulent claims to one Medicare carrier and similarly submitting millions of dollars of bogus

claims to other carriers.

8

Gaming the Health Care System, Billions of Dollars Lost to Fraud & Abuse Each Year, Investigative

Staff Report of Senator William S. Cohen, Ranking Minority Member, Senate Special Committee on

Aging (July 7, 1994).

Page 5 GAO/HEHS-96-18 Targeting of Nursing Facility Patients
B-255730 

supplies was questionable. The Inspector General noted that “the potential

for great profit provides an incentive for fraudulent marketing and billing

schemes which target the entire nursing home population of Medicare

beneficiaries.”9

Services Provided at

Nursing Facilities

Susceptible to Fraud

and Abuse

The nursing facility setting can be an inviting target of opportunity for the

unscrupulous provider of part B services and supplies. First, a vulnerable

population grouped together at a single location offers the opportunity for

volume billing. Second, HCFA’s provisions for reimbursing providers of

these part B services and supplies furnish little early warning of egregious

overutilization or rapid increases in billings.

Nursing Facilities Do Not

Always Monitor Services

or Supplies Furnished by

Outside Providers

Federal requirements call for nursing facilities to perform numerous tasks

to monitor and meet patient care needs, but there are no similar

requirements to monitor claims submitted directly to Medicare for

services or supplies provided to nursing facility patients. HCFA’s

reimbursement system for part B services and supplies allows providers to

bill Medicare without adequate confirmation that the care or items were

necessary or were delivered as claimed. As a result, the program is highly

vulnerable to exploitation. Also, despite the emphasis on patient care, the

cases we reviewed demonstrate that nursing facilities often do not control

provider access to records closely enough and opportunists are permitted

to exploit Medicare.

Nursing facilities generally do not have the in-house capability to provide

all the services and supplies that patients need. Accordingly, outside

providers market their services and supplies to nursing facilities to meet

the needs of the facilities’ patients. OIG has reported that provider

representatives typically enter nursing facilities and offer to handle the

entire transaction—from reviewing medical records to identify those

patients their products or services can help, to billing Medicare—with no

involvement by nursing facility staff.10 Some facilities allow providers or

their representatives to review patient medical records despite federal

9

Statement by Michael Mangano, Principal Deputy Inspector General, Office of Inspector General,

HHS, for Oversight Hearings Before the House of Representatives, Committee on Ways and Means,

Subcommittee on Health (Feb. 6, 1995).

10See Marketing of Orthotic Body Jackets (OEI-04-92-01081, Mar. 1994) and Marketing of Incontinence

Supplies (OEI-03-94-00770, Dec. 1994).

Page 6 GAO/HEHS-96-18 Targeting of Nursing Facility Patients
B-255730 

regulations that prohibit such unauthorized review.11 These

representatives gain access to records not because they have any

responsibility for the direct care of those patients, but because they want

to market their services or supplies. We found that unscrupulous providers

can obtain all the information necessary to order, bill, and be reimbursed

by Medicare for services and supplies that are in many instances not

necessary or even provided. The following are two examples of this

practice:

• A supplier obtained a list of Medicare patients at three nursing facilities

together with their Medicare numbers from another supplier who had

access to specific Medicare billing information for certain patients at these

facilities. The first supplier billed Medicare for large quantities of supplies

that were never provided to these patients and then paid the second

supplier half of the approximately $814,000 it received in reimbursement.

• A group optometrical practice performed routine eye examinations on

nursing home patients, a service not reimbursable by Medicare. The

optometrist was always preceded by a sales person who targeted the

nursing facility’s director of nursing or its social worker and claimed the

group was offering eye examinations at no cost to the facility or the

patient. The nursing facility gave the sales person access to patients’

records, and this person then obtained the information necessary to file

claims. Nursing staff would obtain physicians’ orders for the “free”

examinations, and an optometrist would later arrive to conduct the

examinations. The billings to Medicare, however, were for services other

than eye examinations—services that were never furnished or were

unnecessary.

The OIG and HHS attorneys with whom we spoke agreed that granting

providers of services and supplies unauthorized access to medical records

contributes to fraud and billing abuse.12 They stated that except in specific

cases in which a resident’s safety is jeopardized as a result, HHS lacks clear

authority to impose monetary or other penalties on nursing facilities solely

for providing such access.

11Based on 42 CFR 483.75(l)(4), all information contained in the patients’ records must be kept

confidential except when release is required by (1) transfer to another health care institution; (2) law;

(3) third party payment contract; or (4) the resident.

12OIG refers to this practice in an August 1995 Special Fraud Alert entitled, “Fraud and Abuse in the

Provision of Medical Supplies to Nursing Facilities.”

Page 7 GAO/HEHS-96-18 Targeting of Nursing Facility Patients
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Little Chance of Timely

Detection of Excessive

Medicare Reimbursements

Although carriers employ a number of effective automated controls to

prevent or remedy some inappropriate payments, such as suspending

claims for further review that do not meet certain conditions for payment,

our work shows that outlandish charges or very large reimbursements

routinely escape the controls and typically go unquestioned. The carriers

we reviewed had not put any “triggers” in place that would halt payments

when cumulative claims exceed reasonable thresholds.

Our analysis showed that as a result, Medicare has reimbursed providers,

who were subsequently found guilty of fraud or billing abuses, large sums

of money over a short period without the carrier becoming suspicious. The

following examples highlight the problem:

• A supplier submitted claims to a Medicare carrier for surgical dressings

furnished to nursing facility patients. In the fourth quarter of 1992, the

carrier paid the supplier $211,900 for surgical dressing claims. For the

same quarter a year later, the contractor paid this supplier more than

$6 million without becoming suspicious despite a 2,800-percent increase in

the amount paid.

• A carrier’s payments for a supplier’s body jackets claims averaged about

$2,300 per quarter for five consecutive quarters, then jumped to $32,000,

$95,000, $235,000, and $889,000 over the next four quarters, with no

questions raised by the carrier.13

In other instances, we found that providers subsequently investigated for

wrongdoing billed and were paid for quantities of services or supplies that

could not possibly have been furnished or necessary as these examples

illustrate:

• A carrier reimbursed a clinical psychology group practice for individual

psychotherapy visits lasting 45 to 50 minutes when the top three billing

psychologists in the group were allegedly seeing from 17 to 42 nursing

facility patients per day. On many days the leading biller of this group

would have had to work more than 24 uninterrupted hours to provide the

services he claimed.

• A carrier paid a podiatrist $143,580 for performing surgical procedures on

at least 4,400 nursing facility patients during a 6-month period. For these

services to be legitimate, the podiatrist would have had to serve on

average at least 34 patients per day, 5 days per week.

13A body jacket is a custom-fitted spinal brace made of a rigid plastic material that conforms to the

body and provides a high degree of immobility.

Page 8 GAO/HEHS-96-18 Targeting of Nursing Facility Patients
B-255730 

The Medicare carriers in these two cases did not become suspicious until

they received complaints from family members, beneficiaries, or

competing providers. In other cases, the carriers initiated their

investigations because of their analysis of paid claims (a practice referred

to as postpayment medical review), which focuses on those providers that

appear to be billing more than their peers for specific procedures. One

carrier, for instance, reimbursed a laboratory $2.7 million in 1991 for heart

monitoring services allegedly provided to nursing facility patients and

$8.2 million in 1992. The carrier was first alerted in January 1993 through

its postpayment review efforts when it noted that this laboratory’s claims

for monitoring services exceeded the norm for its peers.

In all these cases, the large increases in reimbursements over a short

period or the improbable cumulative services claimed for a single day

should have alerted carriers to the possibility that something unusual was

happening and prompted an earlier review. For example, people do not

usually work 20-hour days, and billings by a provider for a single

procedure do not typically jump 13-fold from one quarter to the next or

progressively double every quarter.

Limited Recovery of

Losses

Although Medicare carrier postpayment reviews do lead to fraud and

billing abuse investigations, from the perspective of curtailing fraudulent

or abusive billing activities, we found that these reviews often happen too

late. In all the cases cited previously, the carriers did investigate the

providers, but by the time the investigations began, Medicare had already

made millions of dollars in unwarranted payments. The risk to the

Medicare program, as evidenced by the fraud cases we reviewed, is that

relatively little of the money inappropriately paid out is recovered as the

following examples show:14

• The owners of a company that had received over $4.3 million from

Medicare based on fraudulent claims for heart monitoring argued before

the court that $250,000 was the most they could repay. In the settlement

agreement, they agreed to reimburse Medicare $250,000, plus interest, and

be excluded from the Medicare program for 5 years.

• The optometrist mentioned previously who billed for services never

rendered and for undocumented consultations agreed, in a civil

settlement, to refund $30,000 to Medicare over a 35-month period and to

14See also our testimony on this subject, Medicare: Modern Management Strategies Needed to Curb

Program Exploitation (GAO/T-HEHS-95-183, June 15, 1995).

Page 9 GAO/HEHS-96-18 Targeting of Nursing Facility Patients
B-255730 

be excluded from the program for 3 years. Although Medicare had

reimbursed this provider over $450,000 on the basis of false or misleading

claims, the case was settled for less because the provider had no assets

from which the overpayments could be recovered.

• Several companies under investigation since early 1993 for the submission

of false claims for heart monitoring services have billed Medicare large

sums over a 6- to 9-month period and then have gone out of business when

Medicare began making billing inquiries. For example, within a month of

Medicare’s contacting one company for medical records, the

company—which had already been paid at least $1.4 million—closed its

operations making it unlikely that Medicare can recover inappropriate

payments.

Options for

Reimbursing Part B

Claims for Services

Provided to Nursing

Facility Patients

Our analysis showed that a major contributing factor to fraudulent and

abusive billings for services and supplies provided nursing facility patients

is that no one is ensuring that what is billed for is necessary or actually

provided. Because nursing facilities already have a significant role in

planning and providing patient care, they are the likely entity to scrutinize

providers’ reimbursement claims for services administered to the facilities’

patients.

Several options for making nursing facilities accountable for costs

incurred on behalf of their patients were suggested during our discussions

with federal officials and such nursing facility industry representatives as

the American Health Care Association. Each option would require a basic

change in the way Medicare reimburses part B services and supplies

provided to nursing facility patients:

• Unified billing by the nursing facility: Under this approach, the nursing

facility would bill Medicare for all services it is authorized to furnish to

patients, whether payment is sought from part A or B. This would be the

case whether the facility provided the care itself or contracted for the

services or supplies to be provided by someone else. Outside providers

would be prohibited from billing Medicare directly and would, in effect,

have to have agreements with nursing homes. Absent an agreement, the

nursing facility could not bill Medicare because it would not be financially

liable or medically responsible for the care. By contrast, under the current

system, outside providers can bill Medicare directly, without scrutiny by

anyone where the care is delivered. Unified billing by the nursing facility

would make it easier for Medicare to identify all the services furnished to

Page 10 GAO/HEHS-96-18 Targeting of Nursing Facility Patients
B-255730 

residents, which in turn would make it easier to control payments for

those services.

• Capping payments: An alternative to paying on a fee-for-service basis as

Medicare now does is to pay a fixed amount per beneficiary. This

approach mirrors the payment method Medicare uses to reimburse most

health maintenance organizations (HMO) serving Medicare beneficiaries.15

As with HMOs, Medicare would pay the nursing facility a fixed amount per

month for all part B services and supplies provided to each resident

beneficiary.16 A variant, one that would apply only to skilled nursing

facilities, would mirror the way Medicare pays hospitals for inpatient care.

As with hospitals, Medicare would pay nursing facilities a predetermined

fixed amount per patient based on the type of case or diagnosis-related

group into which the patient is classified. Both variants of the capped

payment approach would, by definition, limit Medicare outlays for these

services, eliminating providers’ incentive to provide too many services. By

the same token, the incentive for nursing facilities to profit from accepting

fixed payments while providing fewer services than necessary would need

to be addressed. A further difficulty in these approaches is in establishing

reasonable rates given the wide range of services provided individual

nursing facility patients.

Conclusions Under Medicare neither the nursing facility nor the physician ensure that

the services and supplies outside providers claim to have furnished to

beneficiaries in nursing facilities are in fact necessary and actually

provided. As a result, services provided to Medicare beneficiaries in

nursing facilities offer a target of opportunity for the fraudulent schemes

and billing abuses of the dishonest provider. To address the root cause of

this accountability issue, Medicare needs to change the way it reimburses

for services and supplies furnished patients in nursing facilities. Options

range from those that can be implemented in the short term, such as

allowing only nursing facilities to bill for all services and supplies provided

to their patients, to the more difficult long-term solutions, such as

capitation or prospective payment systems. All these options address the

15HMOs were designed to offer health services less expensively and to constrain the provision of

extensive services, primarily through a reimbursement method known as capitation. Under capitation

Medicare pays HMOs a fixed amount per month for each beneficiary. This method typically places

HMOs at risk for health costs, thereby giving them a financial incentive to control the use of services

and avoid unnecessary care. HMOs may use their own staff of physicians and other providers to

deliver care or may contract with individual providers or medical groups to deliver services.

16The current method for reimbursing risk contract HMOs is not without its problems. See Medicare

Managed Care: Program Growth Highlights Need to Fix HMO Payment Problems

(GAO/T-HEHS-95-174, May 24, 1995).

Page 11 GAO/HEHS-96-18 Targeting of Nursing Facility Patients
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accountability issue, but more study is needed to assess the comparable

costs and benefits of these options.

Certain immediate actions would help stem losses. First, carriers could

establish computerized payment controls that, before payment, would

detect and automatically suspend for further review claims that exceeded

established thresholds for charges and utilization. The thresholds need not

be based on statistical averages, but they should be based on an

assumption about what is reasonable activity for specific procedures,

provider types, beneficiaries, and places of service. Such controls could

provide timely warnings and trigger investigations of potentially

fraudulent and abusive billings before large sums were paid out. Second,

nursing facilities should be held accountable for the unauthorized

disclosure of patient medical records. Giving providers or their

representatives inappropriate access to patient medical records was a

major contributing cause to the fraud and abuse cases we reviewed.

Although such disclosure is contrary to program regulations, HCFA or HHS

generally cannot levy penalties, monetary or otherwise, against a nursing

facility for that unauthorized disclosure.

Recommendation to

the Congress

To curtail the practice of giving providers unauthorized access to

beneficiary medical records, the Congress should authorize HHS OIG to

establish monetary penalties that could be assessed against nursing

facilities that disclose information from patients’ medical records not in

accord with existing federal regulation.

Recommendations to

the Secretary of HHS

We recommend that the Secretary of HHS direct the Administrator of HCFA

to

• establish, for procedure billing codes by provider or beneficiary,

thresholds for unreasonable cumulative levels or rates of increase in

services and charges, and to require Medicare carriers to implement

automated screens that would suspend for further review claims

exceeding those thresholds; and

• undertake demonstration projects designed to assess the relative costs

and benefits of alternative ways to reimburse nursing facilities for part B

services and supplies; these alternatives should include such options as

unified billing by the nursing facility and some form of capped payment.

Page 12 GAO/HEHS-96-18 Targeting of Nursing Facility Patients
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Agency Comments We provided HHS an opportunity to comment on our draft report, but it did

not do so in time for comments to be included in the final report. We did

discuss the report’s contents with HCFA officials who generally agreed with

our findings.

As agreed with your office, unless you publicly announce its contents

earlier, we plan no further distribution of this report until 15 days from the

date of this letter. At that time, we will send copies of this report to the

Secretary of HHS, the Administrator of HCFA, interested congressional

committees, officials who assisted our investigation, and other interested

parties. We will also make copies available to others upon request.

Please call me at (202) 512-7119 or Donald B. Hunter or Roland A. Poirier,

Jr. at (617) 565-7500 if you have any questions.

Sincerely yours,

Edwin P. Stropko

Associate Director

 Health Financing Issues

Page 13 GAO/HEHS-96-18 Targeting of Nursing Facility Patients
Contents

Letter 1

Appendix I 

Scope and

Methodology

16

Appendix II 

Closed Fraud Case

Summaries

18

Case A 18

Case B 19

Case C 20

Case D 21

Case E 22

Case F 23

Case G 24

Case H 25

Related GAO Products 28

Abbreviations

EKG electrocardiogram

HCFA Health Care Financing Administration

HHS Department of Health and Human Services

HMO health maintenance organization

OIG Office of the Inspector General

Page 14 GAO/HEHS-96-18 Targeting of Nursing Facility Patients
Page 15 GAO/HEHS-96-18 Targeting of Nursing Facility Patients
Appendix I 

Scope and Methodology

To develop the information in this report, we interviewed officials at

HCFA’s central office and the HHS Office of the Inspector General in

Baltimore; three Medicare carriers responsible for processing part B

claims in 9 geographic areas; three regional OIG Offices of Investigations

with combined investigative jurisdiction over 17 states; one durable

medical equipment regional carrier responsible for processing durable

medical equipment, prosthetic, orthotic, and supply claims in 14 states and

2 U.S. territories; and trade associations representing both the nursing

home industry and providers of services and supplies. Because

information we obtained from the three Medicare carriers and OIG offices

involves cases under active investigation, we did not disclose the locations

of these offices nor did we reveal identifying details about these cases,

such as the providers’ names and the states in which they operate.

To examine the nature and extent of inappropriate and abusive billing for

services and supplies to nursing facility patients, we (1) asked the carriers’

fraud units to identify cases involving services and supplies provided to

patients in nursing facilities—both ongoing cases and those referred to OIG

in the previous 24 months;17 (2) performed a detailed file review of each

identified case and obtained and reviewed copies of relevant documents;

(3) discussed cases with carrier officials, as needed, and met with OIG

officials to discuss the status of cases that carriers had referred to them

for investigation; and (4) asked OIG officials to identify any additional

investigations completed within the previous 12 months and ongoing

investigations dealing with services and supplies furnished to Medicare

patients in nursing facilities. In all, we reviewed 70 ongoing or completed

investigations. Nearly all of these investigations were initiated by either

the carrier or OIG offices during the 1992 to 1994 time frame. We

interviewed carrier and OIG officials. We also reviewed several

independent studies related to the provision of services and supplies to

nursing facility patients done by OIG and the Senate Special Committee on

Aging.

To examine the reasons inappropriate and abusive billings for services and

supplies occur in the nursing facility setting, we reviewed carrier case files

for each investigation, obtained court documents when applicable, and

interviewed carrier and OIG investigators working on those individual

cases. We analyzed this information to try to identify the specific

programmatic factors that make services for beneficiaries in nursing

facilities vulnerable to fraud and abuse.

17The carriers we visited could not reliably identify all cases under investigation that involved the

provision of services and supplies by outside providers to nursing facility patients. Carriers,

accordingly, had to rely on memory when we asked them to identify such cases.

Page 16 GAO/HEHS-96-18 Targeting of Nursing Facility Patients
Appendix I 

Scope and Methodology

Finally, to identify options for removing opportunities for fraud and abuse,

we reviewed the literature and held discussions with carrier, OIG, and trade

association officials to solicit their views on ways to minimize fraud and

abusive billing practices in the nursing facility environment.

We conducted our review between April 1994 and August 1995 in

accordance with generally accepted government auditing standards.

Page 17 GAO/HEHS-96-18 Targeting of Nursing Facility Patients
Appendix II 

Closed Fraud Case Summaries

Following are summaries of fraud cases that were closed by the time we

completed our review. The defendants pled guilty or were convicted of the

charges brought against them.

Case A In August 1991, a carrier received the first of three complaints from

Medicare beneficiaries alleging that an optometrist was billing Medicare

for more services than he actually provided. After reviewing the

supporting medical records, however, the carrier determined that for these

instances the services were documented as billed. In December 1991,

another beneficiary called the carrier and stated that she had not received

the office services claimed by this optometrist and in fact had not seen any

physician during the month he claimed services were provided. Another

complaint was received from the daughter of a beneficiary residing in a

nursing home. The daughter stated that she had only authorized an eye

examination, but the charges submitted to Medicare were for multiple

services provided for both eyes—although her father had only one eye. In

January 1992, the carrier’s claims processing department alerted the

carrier’s program integrity unit of 98 suspicious claims submitted by this

provider for services allegedly rendered in December to nursing home

patients. All the claims cited exactly the same procedure codes and

diagnoses; the only differences were dates of service and beneficiary

identification information. From this universe, the carrier randomly

sampled 10 beneficiary records from two nursing homes and found that

the nursing homes had no records documenting the services claimed by

this optometrist. On May 21, 1992, the carrier summarized this information

and referred the case to OIG. By that time, Medicare had paid this provider

$117,534 since 1990.

OIG notified the carrier in June 1992 that it would not pursue this case

criminally but that it would retain jurisdiction for civil prosecution. At

OIG’s request, the carrier placed this provider on 100-percent prepayment

review by the end of July, which meant that every claim the provider

submitted was reviewed before payment was issued. Additionally, the

carrier completed a postpayment review on this provider’s billings and

reported in January 1993 that medical necessity appeared questionable for

many claims and that nursing home visits and consultation requests were

not documented. The optometrist requested a hearing before the Medicare

hearing officer to review the carrier’s continuing reimbursement denials.

The hearing officer ruled in November 1993 that all 157 claims submitted

for diagnostic eye services for 154 nursing home patients between August

and October 1992 were questionable. The carrier had denied all but three

Page 18 GAO/HEHS-96-18 Targeting of Nursing Facility Patients
Appendix II 

Closed Fraud Case Summaries

of these claims, but the hearing officer ruled that these too were overpaid.

According to carrier files, the optometrist was still on prepayment review

in March 1994. Although the optometrist’s billing volume had significantly

decreased, the carrier noted that he continued to bill for the same type of

procedures previously denied. As late as October 1994, the carrier was still

receiving complaints about this provider.

On January 16, 1995, the optometrist signed a settlement agreement in U.S.

District Court whereby he admitted to knowingly filing false, misleading,

or otherwise fraudulent Medicare claims for services either not medically

necessary or not provided from 1991 through 1993 for which Medicare had

paid him over $191,276. Under this agreement he would repay $35,000 and

be excluded from the Medicare program for at least 3 years. The exclusion

would extend for as long as the $35,000 assessed against him was not

repaid.

Case B A beneficiary’s husband complained to the Medicare carrier that a supplier

was billing Medicare for more supplies than it actually provided for his

wife. The carrier referred this case to OIG, which opened its investigation

on December 7, 1990. The company in question focused on publicly funded

facilities in several states, such as state veterans homes or state-funded

chronic disease or long-term care hospitals. The owner would approach

facility administrators and offer to provide supplies for Medicare patients

at no cost to the facility. This was an attractive proposition to these

facilities, which typically have limited financial resources. The facility

administrators gave the provider complete access to patient medical

records. The suppliers reviewed all records, identified Medicare

beneficiaries, obtained their Medicare numbers, developed lists of supplies

based on diagnoses, identified attending physicians, and made copies of

signed physician orders in the files. The supplier then billed Medicare for

ostomy, enteral, or surgical dressing supplies that it delivered after

September 1990, but it also billed for supplies it had never delivered to

those beneficiaries over the previous 2 years. The supplier provided

certificates of medical necessity by forging the attending physicians’

signatures on the certificates using samples of signed orders found in the

patients’ files. The case involved about 4,000 fraudulent claims totaling

about $1.5 million.

The defendant was indicted on April 6, 1994, and pled guilty on May 5,

1994, to mail fraud, engaging in monetary transactions in criminally

derived property, money laundering, and Medicare fraud. The defendant

Page 19 GAO/HEHS-96-18 Targeting of Nursing Facility Patients
Appendix II 

Closed Fraud Case Summaries

agreed to forfeit all property resulting from these fraudulent transactions,

including about $328,000 in several bank accounts. The defendant was

sentenced on October 19, 1994. This judgment was amended on

November 21, 1994, to finalize the overpayment amounts. He was

sentenced to 54 months in federal prison. Upon release from

imprisonment, the defendant would be on supervised release for a term of

3 years provided he had made restitution as ordered by the court of

$971,000 to Medicare and $60,000 to Medicaid.

Case C A Medicare carrier’s fraud and abuse unit received over 30 complaints

from beneficiaries, family members, and other informants that a provider

was billing for supplies that had not been furnished or were not needed. In

August 1991, the carrier referred the case to OIG for investigation. OIG

found that from April through June 1991, the provider filed claims totaling

$666,560 on behalf of 1,096 beneficiaries for 65,833 liquid skin barriers. In

addition, the provider filed claims totaling $11,406 on behalf of 319

beneficiaries for 1,210 adhesive removers or solvents. Medicare had paid

the provider a total of $263,222 for both items, and most of the claims were

for beneficiaries who were residing in nursing homes in another state. In

addition to the payments made, the carrier was withholding payment on

9,500 claims totaling about $3.5 million.

OIG visited the provider and found that the provider rented a small office

and apparently did not furnish any supplies from this location. The

provider, in effect, was a storefront operation or shell company. OIG

believed the supplies originated from the provider’s parent company

located in another state that also owns supply companies in at least six

other states. On the basis of its investigation, OIG believed the provider had

(1) billed Medicare for items that were not supplied, (2) misrepresented

the items that were supplied, (3) misrepresented the place of service,

(4) misrepresented the medical conditions of patients who received the

supplies, and (5) paid kickbacks to nursing home officials to induce

business. Also, OIG found that the provider gained access to patient

medical records, obtaining diagnostic information and the names of

beneficiaries’ attending physicians. The provider then entered the

physicians’ names on claim forms; physician orders were often

nonexistent. OIG concluded that the supplier served merely as a conduit for

submitting claims to the Medicare carrier and receiving checks. The funds

were then transferred to the parent company.

Page 20 GAO/HEHS-96-18 Targeting of Nursing Facility Patients
Appendix II 

Closed Fraud Case Summaries

On April 24, 1995, an officer of the parent company pled guilty to

submitting more than $4.4 million of false and fraudulent claims to one

Medicare carrier and similarly submitting millions of dollars worth of false

and fraudulent claims to other Medicare carriers. The provider billed

Medicare for supplies at inflated rates as well as for supplies that were not

provided or not medically necessary—including billing supplies for

patients who had died. In one instance, the provider billed Medicare $2,790

for surgical dressing kits that were never provided; instead, the provider

furnished the patient 62 gauze bandages costing less than $20. Under a

plea agreement, the officer of the company agreed to cooperate with

federal authorities in their attempts to identify others involved in the

conspiracy. In return, the U.S. Attorney will recommend a prison term not

to exceed 15 months.

Case D After reviewing a Medicare explanation of benefits notice, a beneficiary’s

son questioned why his mother—a nursing home resident—received such

large quantities of supplies. In investigating the matter, the Medicare

carrier determined that the provider was billing for supplies that were not

provided. OIG began its investigation in July 1990. On November 8, 1990, a

federal grand jury returned a 623-count indictment against the two

providers it alleged obtained payment for false, fictitious, and fraudulent

claims submitted for approximately 120 nursing home patients in three

facilities in different states. One supplier (supplier #1) submitted the false

claims to the carrier knowing that the supplies had never been provided.

Another supplier (supplier #2) had given supplier #1 billing information for

the patients in the three nursing facilities—patient names, Medicare

numbers, diagnoses, treating physicians, and so forth. As part of the

conspiracy, supplier #2 received a kickback from supplier #1 equal to

50 percent of the money received from the carrier for the false claims.

Between June 7 and August 8, 1990, the carrier paid about $813,973 for

false claims—an average of about $6,783 per patient.

On September 30, 1991, as a result of plea-bargaining, supplier #2 pled

guilty to one count of conspiracy to defraud the United States with respect

to claims, one count of submitting false claims, and one count of mail

fraud. On January 9, 1992, the vice president of supplier #2 was sentenced

to 26 months in jail and ordered to repay $75,000 to HHS and pay a special

assessment of $150. The company itself was also fined $5,000 and ordered

to pay a special assessment of $100. On November 6, 1991, supplier #1 was

found guilty after trial of all 623 counts. On February 4, 1992, the president

of supplier #1 was sentenced to 24 months of incarceration and ordered to

Page 21 GAO/HEHS-96-18 Targeting of Nursing Facility Patients
Appendix II 

Closed Fraud Case Summaries

repay $300,000 to HHS and pay a special assessment of $31,150. The

company was also fined $1,000 and ordered to pay a special assessment of

$62,200.

In November 1994, a civil case against supplier #1 was settled with a

summary judgment. Supplier #1—which is out of business and

bankrupt—was ordered to pay $4,955,000. Toward this amount, the

government applied the $407,121 seized from the company’s corporate

account and has up to 30 years to recover the remainder of the funds from

the president of the company.

Case E On February 3, 1992, a Medicare carrier received a complaint forwarded

from the daughter of a beneficiary. The complaint concerned a wheelchair

cushion that should have cost less than $100 but that was charged to

Medicare as a $1,503 custom-fitted body jacket. After receiving several

complaints from family members of other nursing home residents and

nursing home staff, the carrier noted the increased billings by the supplier

submitting this claim and started to review related nursing home records.

Carrier medical staff determined that services the supplier billed Medicare

for were not provided, beneficiaries were not measured for a custom fit,

the beneficiaries’ condition could not be improved by using the jackets,

physical therapy was billed for but neither ordered nor received, and the

physicians only signed prescriptions that had been prepared by someone

else. By mid-May, the carrier had received 38 complaints against this

supplier of which 34 pertained to body jackets. By mid-August, the

inquiries concerning this supplier had increased to 50. The carrier referred

this case to OIG on August 25, 1992.

OIG’s investigation revealed that this supplier actually started marketing

wheelchair cushions with adjustable straps as Medicare-reimbursable

custom-fitted body jackets in 1991. Sales representatives for the supplier

would market the body jackets to the directors of nursing as fully

Medicare covered and promise that no real attempt would be made to

collect the co-payments from the beneficiaries. They would offer to go into

the nursing facility files to obtain the patient information needed to

prepare claims and certificates of medical necessity. Usually, the facility

allowed such access; in other cases, the facility provided the necessary

information. In some cases, the supplier gained access to nursing homes

by providing kickbacks in the form of payments on insurance policies or

to individuals to induce them to order exclusively from this supplier.

Page 22 GAO/HEHS-96-18 Targeting of Nursing Facility Patients
Appendix II 

Closed Fraud Case Summaries

The sales people obtained physicians’ signatures on the certificates of

medical necessity by assuring physicians that the director of nursing had

requested the items and that the items would cost the patients nothing.

The certificates would be sent to the supplier’s headquarters, where

employees would add or delete wording from the signed certificates to

guarantee Medicare payment. By December 1992, Medicare had paid this

supplier over $1.6 million for wheelchair cushions misrepresented as body

jackets.

Seven persons involved in this fraudulent scheme were indicted and pled

guilty; all were sentenced in fall 1994. The owner of the company was

sentenced to 33 months in jail followed by 3 years on supervised release

and was ordered to make restitution to Medicare of $386,508. Two other

principal defendants connected with the firm were placed on probation for

5 years and each was ordered to make restitution of $386,508. Two

persons convicted of receiving kickbacks were each placed on probation

for 5 years and fined $9,000 and $10,000, respectively. (Two other

defendants, who assisted in the investigation, pled guilty to lesser charges

and executed agreements for pretrial diversion. Under these agreements, if

they provided 100 hours of community service and abided by the

conditions of the agreement, charges against them would be dismissed

after 1 year and the record would be erased.)

Case F In September 1992, the granddaughter of a beneficiary reported to the

carrier that her grandmother had never received a custom-fitted back

brace (commonly referred to as a body jacket) that had been billed to

Medicare by this supplier. One month later, a similar complaint was

received from the husband of another beneficiary. The following month,

the daughter of a third beneficiary wrote to the carrier complaining of a

claim for a body jacket that her mother did not need or use. When she

went to the nursing home, she learned that her mother and others had

refused to accept the body jackets and the nursing home had put them in

storage. After talking to the administrator and nurses at the home, the

daughter learned that a representative of the supplier came to the nursing

home, checked patients’ records, and left forms to be completed for

products the patients qualified for. This complainant stated that this

supplier appeared to be operating out of a residence: there was no

telephone listing for the company. In December, the daughter of another

beneficiary wrote to the carrier complaining about the “ridiculous” charge

for a body jacket that was provided without her knowledge or consent.

Page 23 GAO/HEHS-96-18 Targeting of Nursing Facility Patients
Appendix II 

Closed Fraud Case Summaries

This supplier was established for the sole purpose of selling body jackets,

which it sold primarily to nursing home patients. Company representatives

went to nursing homes to sell wheelchair pads, which they asserted were

reimbursable by Medicare. These representatives told nursing home

personnel and beneficiaries that the beneficiaries would not be

responsible for any costs not reimbursed by Medicare. The company

representatives also prepared certificates of medical necessity for the

wheelchair pads sold and obtained physicians’ signatures. The company

then billed Medicare for body jackets. According to carrier

correspondence, this supplier had been reimbursed $564,808 for body

jackets from July 1, 1992, through December 31, 1993.

On March 24, 1993, the carrier referred this case to OIG, noting that on the

basis of the allegations and information it had obtained, the body jackets

billed did not appear to be customized and the prescriptions appeared to

be completed by someone other than the listed physicians. In its referral

letter, the carrier reported that this supplier had received nearly $416,000

from Medicare during the last 6 months of 1992. All claims were for a

$1,289 body jacket.

On June 16, 1995, a plea agreement was filed in court in which the

company pled guilty to one count of mail fraud and agreed to repay

$450,000 to Medicare. As part of the consideration for this plea agreement,

the president of this company agreed to testify before grand juries or at

trials on matters involving other persons under investigation for this same

type of fraudulent scheme.

Case G A Medicare carrier’s fraud and abuse unit began investigating a laboratory

on January 29, 1991, on the basis of a complaint by a beneficiary’s

daughter. The daughter stated her mother did not order the services for

which Medicare paid the laboratory $142. Nor had the services been

ordered by the beneficiary’s doctor or the nursing home where the

beneficiary resided. The carrier reviewed the pertinent medical records for

15 beneficiaries in three nursing homes in two different states and found

that none of the services were medically necessary. For 14 beneficiaries,

there were no physician orders requesting the services, and for the

remaining beneficiary, the diagnosis submitted with the claim was not

documented. The carrier identified an overpayment of $10,520 for 19

claims paid during a 4-month period.

Page 24 GAO/HEHS-96-18 Targeting of Nursing Facility Patients
Appendix II 

Closed Fraud Case Summaries

On August 13, 1991, the carrier referred this case to OIG for further

investigation. Following this referral, the carrier received several

additional complaints against this laboratory. For example, a beneficiary’s

legal guardian learned that Medicare paid the laboratory $706 for the

telephonic transmission of 21 electrocardiogram (EKG) rhythm strips over

a 2-week period. She contacted the beneficiary’s physician and learned

that the physician did not authorize or have any prior knowledge of such

tests. In another complaint, a former employee stated the laboratory’s

salespeople contacted doctors regarding its cardiac monitoring system. If

doctors signed up for the service, they had to provide listings of their heart

patients in nursing homes. The laboratory then sent people to the nursing

homes to perform 21 EKGs on each patient over an 11-day period, with the

series of tests to be repeated three more times during the year. The

laboratory charged about $1,000 per patient for the 11-day study, or about

$4,000 per year per patient. However, the doctors generally did not see the

results of the studies. The laboratory operated all over the country; one

doctor alone had 275 patients on this program.

As a result of its investigation, OIG concluded that most of the laboratory’s

billings for these services were inappropriate. OIG found that the

laboratory was billing Medicare for EKGs that were rendered as routine

screening diagnostic tests, with no evidence of a physician evaluation and

no indication that the patients were experiencing an arrhythmia, symptom,

or complaint. OIG pursued the case as a civil false claims case because the

diagnoses entered on the Medicare claim forms by the laboratory were

false—they did not accurately reflect the patients’ conditions at the time

the EKG services were ordered and rendered. OIG estimated that the actual

Medicare overpayment in this case was about $6 million.

On February 10, 1994, the laboratory and its three principal owners

entered into an agreement to reimburse HHS $250,000 plus $16,118 in

interest for inappropriate claims. In addition, the laboratory waived any

future demands for $655,086 in payments (identified through a special

prepayment review effort) that the Medicare carrier had withheld—thus

resulting in a total settlement of $921,204. Finally, the provider and its

three owners were excluded from participating in the Medicare program

for a 5-year period effective February 10, 1994.

Case H The carrier initiated its review of this optometrist and the group optometry

practice he owns on September 11, 1990. This review was based on a

beneficiary’s letter to the carrier dated July 7, 1990, alleging that the

Page 25 GAO/HEHS-96-18 Targeting of Nursing Facility Patients
Appendix II 

Closed Fraud Case Summaries

optometrist performed only an eye examination, not the surgery he had

claimed and had been reimbursed for by Medicare. By the time the carrier

referred the case to OIG on July 30, 1991, it had received 19 complaints

against the group practice and 2 against the individual; 19 of these

complaints involved beneficiaries in nursing homes. The complaints

alleged that the providers had billed Medicare for services that were never

furnished or that were not necessary. According to a nursing home

administrator, a representative of the group practice would visit nursing

homes, review patient records, and obtain the necessary patient

information to file Medicare claims. Several days later, an optometrist

would visit the nursing home and render services.

After reviewing nursing home medical records for 20 beneficiaries, the

carrier concluded that the services billed were not medically necessary or

not documented. The provider submitted the same diagnosis and tests on

all claims. The claims identified a referring physician and charges for

consultations, but the records contained no orders requesting

consultations. On May 15, 1992, OIG requested that the carrier place both

the individual optometrist and the group practice on 100-percent

prepayment review.

While this case was open, this optometrist wrote not only to the carrier but

also to his congressional delegation alleging discrimination against him as

an optometrist. He also enlisted the help of his patients to write to

Medicare of his successes and to provide copies of those letters to their

Congress Members and Senators. However, the case had nothing to do

with the technical merits of his optometry practice. He was billing

Medicare for services never rendered to patients and for consultations for

which the medical files showed no physician requests. A civil settlement

was signed on December 14, 1994, and filed in U.S. District Court on

January 20, 1995. Although Medicare reimbursed this provider over

$451,617 based on false, misleading, or otherwise fraudulent claims, the

settlement involved a refund of $30,000 to be paid over a 35-month period

and voluntary exclusion from the Medicare program for 3 years. If the

defendant defaults on the financial obligation, the exclusion continues

until the obligation is fully satisfied.

Page 26 GAO/HEHS-96-18 Targeting of Nursing Facility Patients
Appendix II 

Closed Fraud Case Summaries

Page 27 GAO/HEHS-96-18 Targeting of Nursing Facility Patients
Related GAO Products

Fraud and Abuse: Medicare Continues to Be Vulnerable to Exploitation by

Unscrupulous Providers (GAO/T-HEHS-96-7, Nov. 2, 1995).

Medicare: Modern Management Strategies Could Curb Fraud, Waste, and

Abuse (GAO/T-HEHS-95-227, July 31, 1995).

Medicare: Adapting Private-Sector Techniques Could Curb Losses to Fraud

and Abuse (GAO/T-HEHS-95-211, July 19, 1995).

Medicare: Rapid Spending Growth Calls for More Prudent Purchasing

(GAO/T-HEHS-95-193, June 28, 1995).

Medicare: Modern Management Strategies Needed to Curb Program

Exploitation (GAO/T-HEHS-95-183, June 15, 1995).

Medicare: Reducing Fraud and Abuse Can Save Billions (GAO/T-HEHS-95-157,

May 16, 1995).

Medicare Claims Billing Abuse: Commercial Software Could Save

Hundreds of Millions Annually (GAO/T-AIMD-95-133, May 5, 1995).

Medicare and Medicaid: Opportunities to Save Program Dollars by

Reducing Fraud and Abuse (GAO/T-HEHS-95-110, Mar. 22, 1995).

Medicare: High Spending Growth Calls for Aggressive Action

(GAO/T-HEHS-95-75, Feb. 6, 1995).

(101291) Page 28 GAO/HEHS-96-18 Targeting of Nursing Facility Patients
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