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The Centers for Medicare and Medicaid Services has a valuable information resource for identifying and addressing the potential abuse and neglect of Medicare beneficiaries.

That’s the contention of the Department of Health and Human Services’ Office of the Inspector General.

An OIG audit discovered 34,664 Medicare claims that contained diagnosis codes indicating the treatment of injuries potentially caused by abuse or neglect of Medicare beneficiaries.

“We estimated 30,754 of these Medicare claims were supported by medical records that contained evidence of potential abuse or neglect,” states OIG’s report. “We further estimated that, of the claims in our population associated with incidents of potential abuse or neglect, 2,574 were allegedly perpetrated by a healthcare worker, 3,330 were related to incidents that occurred in a medical facility, and 9,294 were related to incidents that were not reported to law enforcement.”

At the same time, auditors noted that CMS did not identify the Medicare claims that indicate potential abuse or neglect because the agency did not extract Medicare claims data containing the 17 diagnosis codes.

“The lack of a data extract impeded the ability of CMS or of public and patient safety organizations to pursue legal, administrative and other appropriate remedies to ensure the safety, health and rights of Medicare beneficiaries,” concludes the OIG.

To address the problem, the OIG recommended that CMS take the following actions:

  • Compile a complete list of diagnosis codes that indicate potential physical or sexual abuse and neglect.
  • Use that complete list to conduct periodic data extracts of all Medicare claims containing at least one of those codes.
  • Inform states that the extracted Medicare claims data are available to help states ensure compliance with their mandatory reporting laws.
  • Assess the sufficiency of existing federal requirements, such as conditions of participation and section 1150B of the Social Security Act, to report suspected abuse and neglect of Medicare beneficiaries, regardless of where services are provided and strengthen those requirements or seek additional authorities as appropriate.

While CMS concurred with the OIG’s fourth recommendation in written comments to the report, the agency did not agree with the first three recommendations.

“Specifically, CMS stated that claims data may not be timely enough to address acute problems in identifying and addressing potential abuse or neglect of Medicare beneficiaries,” according to auditors. “We respectfully disagree with CMS and continue to recommend the use of the Medicare claims data to identify and address potential abuse and neglect of beneficiaries.”


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