Fighting Improper Payments And Fraud – Protecting Taxpayer Dollars

By Marilyn Tavenner, Acting Administrator of the Centers for Medicare & Medicaid Services (CMS)

Fighting fraud and waste in the health care system is a top priority for the Obama Administration.  We are committed to using all resources at our disposal in these efforts – and they are paying off.

Just last week, the Departments of Justice and Health and Human Services (HHS) released an updated annual report showing that in FY 2011 anti-fraud efforts have recovered more than $4.1 billion in fraudulent Medicare payments – the second year in a row recovery efforts reached this unprecedented level.  Compare this to just $2.14 billion recovered in FY 2008.  Prosecutions are way up too:  the number of individuals charged with fraud increased from 821 in fiscal year 2008 to 1,430 in fiscal year 2011 – nearly a 75 percent increase.

But we know we need keep doing more to end the “pay and chase” model of fighting fraud.  We need to stop fraud and waste from happening in the first place.  Today we’re taking an important step to protect taxpayer dollars by reducing improper payments to Medicare Advantage plans, an action that is estimated to save $370 million in the first audit year alone.  By improving the way we audit Medicare Advantage contracts, we will reduce the payment error rate for the Medicare Advantage program  and that saves money for Medicare.

We are also using new, advanced techniques to fight fraud.  Starting last year, we have been using “predictive modeling” technology – similar to technology used by credit card companies to identify and fight fraud nationwide.  This effort is just getting started but it’s already making a difference. Since the predictive modeling system was activated, CMS has stopped, prevented or identified $20 million in payments through November 2011 that should not have been made.

In addition, predictive modeling has identified 2,500 leads for further investigation, 600 preliminary law enforcement cases under review and resulted in 400 direct interviews with providers who would not have otherwise been contacted.

Predictive modeling won’t reach its full potential in overnight, but it’s already making an incredible difference and will do even more in the weeks, months and years ahead.

More than 30 million with Medicare used free preventive services in 2011

Health and Human Services Secretary Kathleen Sebelius announced today that the Affordable Care Act provided approximately 54 million Americans with at least one new free preventive service in 2011 through their private health insurance plans. Secretary Sebelius also announced that an estimated 32.5 million people with Medicare received at least one free preventive benefit in 2011, including the new Annual Wellness Visit, since the health reform law was enacted.

Together, this means an estimated 86 million Americans were helped by health reform’s prevention coverage improvements. The new data were released in two new reports from HHS.

“Americans of all ages can now get the preventive services they need, like mammograms and the new Annual Wellness Visit, free of charge, as a result of the new health care law,” Secretary Sebelius said. “With more people taking advantage of these benefits, more lives can be saved, and costly, and often burdensome, diseases can be prevented or caught earlier.”

The Affordable Care Act requires many insurance plans to provide coverage without cost sharing to enrollees for a variety of preventive health services, such as colonoscopy screening for colon cancer, Pap smears and mammograms for women, well-child visits, and flu shots for all children and adults. The law also makes proven preventive services free for most people on Medicare.

The report on private health insurance coverage also examined the expansion of free preventive services in minority populations.  The results showed that an estimated 6.1 million Latinos, 5.5 million Blacks, 2.7 million Asian Americans and 300,000 Native Americans with private insurance received expanded preventive benefits coverage in 2011 as a result of the new health care law.

The report discussing Medicare preventive services found that more than 25.7 million Americans in traditional Medicare received free preventive services in 2011. The report also looked at Medicare Advantage plans and found that 9.3 million Americans – 97 percent of those in individual Medicare Advantage plans – were enrolled in a plan that offered free preventive services.  Assuming that people in Medicare Advantage plans utilized preventive services at the same rate as those with traditional Medicare, an estimated 32.5 million people benefited from Medicare’s coverage of prevention with no cost sharing.

The full report on expanded preventive benefits in private health insurance is available at  The report on expanded preventive benefits in Medicare and other ways that the Affordable Care Act strengthens Medicare is available at

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Take the time to prevent heart disease

Statement from Secretary Sebelius on American Heart Month

Crosspost from

February is American Heart Month; a month to spread awareness about the importance of heart health. Each year, countless American families are impacted by heart disease and stroke. Although its risk factors can be prevented or controlled, it is still the leading cause of death for all Americans, and accounts for $1 out of every $6 dollars spent on health care.  Fortunately, there are many simple steps we can take to prevent heart disease such as eating healthy foods, exercising regularly, and not smoking.

The Department of Health and Human Services is working with both public and private partners to raise awareness of heart disease through vital research investments and public health programs. The Million Hearts Initiative takes aim at this disease, with a goal of preventing 1 million heart attacks and strokes over the next 5 years. Other efforts, like the HeartTruth, which addresses women’s heart health, and the First Lady’s Let’s Move! initiative, which confronts childhood obesity by helping children choose healthy foods and stay active, work to provide people with resources and ways to make heart healthy changes in their everyday lives .

And thanks to the new health care law, the Affordable Care Act, new health plans must now cover recommended preventive services, including blood pressure screening for all adults and cholesterol screening for adults of certain ages or at higher risk, cost-free.

This month, as we take time to educate ourselves about the risks of heart disease, and recognize the efforts of medical researchers and healthcare professionals dedicated to prevention, early detection, and effective treatment, consider what steps you and your family can take to promote and adopt a heart healthy lifestyle.

For more information on American Heart Month, please visit:

For more information on women and heart disease, please visit: or  .  

To learn more about the First Lady’s Let’s Move campaign, please visit:

Medicare Covers Tests to Find Heart Disease Early

Heart disease is the leading cause of death in the United States, so it’s important to take care of your heart to stay healthy. Start now, during American Heart Month, by talking to your doctor about whether you’re at risk for heart disease and to schedule your free cardiovascular screening. Medicare covers these tests, which help detect heart disease early and check your cholesterol, blood fat (lipid), and triglyceride levels.

 Medicare will cover a cardiovascular screening at no cost to you every 5 years, so be sure to schedule your screening to get the most out of your Medicare.

 If your doctor thinks you’re at risk for a heart attack or stroke, there are steps you can take to help prevent these conditions, such as take medication. Your doctor may also suggest you make the following lifestyle changes to lower your cholesterol and stay healthy:

  •          Change your diet
  •          Increase your activity level
  •          Exercise more often

Making lifestyle changes can be challenging, but you don’t have to reach your heart health goals alone. Join Million Hearts, a national campaign to help prevent 1 million heart attacks and strokes over the next 5 years. Join now to get the information and resources you need to learn how to take care of your heart and live a healthy life.

 For more information on heart disease risks and prevention, visit the Centers for Disease Control or the American Heart Association.