The Center for Public Integrity

A government panel’s controversial recommendation that healthy men should no longer be routinely screened for prostate cancer is fueling a continuing debate over unnecessary Medicare spending for cancer screening — the subject of a recent iWatch News investigation.

Last week, draft guidelines of the U.S. Preventive Services Task Force advised men against routine prostate cancer screening using the prostate-specific antigen (PSA) test because the test often leads to more harm than good, with the potential for harm posed by aggressive treatment offsetting any gain.

The findings were strongly disputed by the American Urological Association, which called the task force recommendations a disservice to men. The urologists say the test saves lives and provides important information to men about their health. On Friday, however, the Annals of Internal Medicine published an outside panel’s review of evidence backing the task force recommendations.

Terry Waddell knew that her 87-year-old mother did not have long to live. The woman’s organs were shutting down because of old age, she said, and her arthritic body had withered to 80 pounds.

So, when Waddell received a call about her mother’s health, it was not what she expected. A visiting nurse had noticed a bit of blood between the frail woman’s legs and wanted her screened for cervical cancer.

Waddell, of Houston, regrets that she took her mother for the test. She refused to let doctor’s aides weigh her, she said, protesting that getting her mother out of her wheelchair was too arduous a process. Then came the actual exam, which she said “was painful to watch.” Her mother struggled to open her legs wide enough for the procedure and then lay there, quietly crying.

“I blame myself for not stopping this,” said Waddell, whose mother died two months later.“It was totally unnecessary.” Unnecessary, perhaps, but surprisingly common.

Cancer screening tests are vastly overused in the United States, with about 40 percent of Medicare spending on common preventive screenings regarded as medically unnecessary, an iWatch News investigation reveals. Millions of Americans get such tests more frequently than medically recommended or at times when they cannot gain any proven medical benefit, extracting an enormous financial toll on the nation’s health care system. Doctors disregard scientific guidelines out of ignorance, fear of malpractice suits or for financial gain, as patients inundated by medical advertising clamor for extra tests.

In the frenzied hunt for cancer, the risks of the screenings also get overlooked. Besides producing anxiety, screening people for cancer can itself cause injuries — even death — or set off a cascade of expensive tests and treatments that can waste more money and create more problems.

Tens of thousands of Medicare beneficiaries are obtaining prescriptions for addictive drugs from multiple doctors, says a new auditor’s report, underscoring the need for Medicare to better police its drug benefit program – an issue highlighted early this year by iWatch News.

During 2008, 170,000 Medicare Part D beneficiaries acquired frequently abused drugs — primarily hydrocodone and oxycodone — from five or more doctors, at a cost of $148 million, according to a report to be released later today by the Government Accountability Office (GAO).  According to the investigation on so-called doctor shopping, 600 Medicare beneficiaries received prescriptions from as many as 87 medical practitioners in the same year.

The GAO said the Centers for Medicare and Medicaid Services (CMS) has systems in place to identify inappropriate drug use by beneficiaries, but said that “measures to stop the activity are limited.” The watchdog agency also said stricter controls over prescription drugs are needed to reduce drug abuse and addiction. CMS is part of the Department of Health and Human Services.

In addition to addicts who seek out drugs for personal use, Medicare has long been a lucrative target for criminals who exploit the program for profit. Attorney General Eric Holder estimated the program loses $60 billion a year to fraud.

Two prominent Republican senators are pushing Medicare’s administrator to block convicted felons and doctors with revoked licenses from successfully billing the federal health care program for the elderly, an issue that was highlighted by iWatch News early this year.

In the letter to Donald Berwick, administrator of the Centers for Medicare and Medicaid Services (CMS), Sen. Orrin Hatch, R-Utah, and Sen. Tom Coburn, R-Oklahoma, wrote that Medicare contractors are allowing doctors and scam artists to retain Medicare billing privileges even if they have lost their medical licenses or have been convicted of felonies related to tax evasion, health care fraud, and “lewd and lascivious conduct.”  Medicare contracts with 11 companies nationwide to administer claims for the program. The letter also includes a list of possibly dubious practitioners and a request that CMS determine if they should be revoked from the program.

“By not taking the appropriate administrative action against providers and suppliers who are convicted or who have pled guilty to financial crimes and other felonies … CMS is abdicating its financial responsibility and placing Medicare beneficiaries at increased risk of poor quality health care,” the senators wrote.

A Medicare investigation has turned up more than $100 million in questionable payments for artificial legs and feet, including suppliers in Alabama, Mississippi, Wyoming and Puerto Rico who were twice as likely to turn up in the inspector general’s sights.

Between 2005 and 2009, Medicare expenditures for lower limb prostheses increased 27 percent, to $655 million. Even as spending increased, approximately 2,000 fewer people benefitted, according to the Department of Health and Human Services inspector general’s report.

Medicare made at least $43 million in unnecessary payments in 2009—all because government contractors weren’t careful enough when they processed claims for prosthetic lower limbs. It also paid $61 million that year for beneficiaries who did not have claims from a referring physician. Without a referring physician, the risk that a claim is fraudulent increases.

The Centers for Medicare & Medicaid Services, the federal agency that administers Medicare, contracts with numerous companies to process and pay claims for artificial legs and feet. Several of these contractors failed to observe some of the best practices identified by the report, resulting in claims that were medically unnecessary or did not include a referring physician. Additionally, only two of the contractors analyzed claims with a particular eye toward their legitimacy.

“These payments—for 32,260 claims for 9,265 beneficiaries—could have been prevented if claims processing edits had been in place,” the report said.

Medicare spent $47.9 billion in one year for health care treatments and equipment that were not medically necessary, miscoded by providers, or lacked proper documentation.

Only a small amount of the $47.9 billion in improper payments reported in 2010 was due to fraud, according to Daniel Levinson, inspector general for the Health and Human Services Department.

Some 94 percent of the improper payments were made to durable medical equipment suppliers, hospitals, skilled nursing facilities, home health agencies and physicians, Levinson told a U.S. House Oversight and Government Reform subcommittee on Thursday.

For example, 57 percent of claims for wheelchairs were either not medically necessary or did not have the required documentation, he said.  As a result, Medicare paid $95 million over a six-month period for wheelchairs that the government insurance plan should not have paid.

Additionally, 60 percent of claims submitted to Medicare for power wheelchairs were not documented properly, resulting in $112 million in improper payments over six months, he said.

The inspector general said his office plans to examine a group of what he described as “error-prone” providers who have submitted a number of incorrect claims in the past four years. The internal watchdog is also taking a closer look at bills submitted by power wheelchair providers, nursing homes, home health care agencies and hospitals to prevent incorrect payments, he said.

Two senators introduced bipartisan legislation Wednesday that aims to crack down on fraud in federal health programs for the poor and the elderly.

The Medicare and Medicaid Fighting Fraud and Abuse to Save Taxpayer Dollars Act, introduced by Sens. Tom Carper, D-Del., and Tom Coburn, R-Okla., includes a provision that would require all prescriptions paid for by the Medicare Part D prescription drug plan include a valid physician identifier. That is currently not required.

In February, iWatch News reported that the use of invalid physician prescriber numbers is so common that the program cannot identify the top physician prescribers of oxycodone and Ritalin, two highly addictive drugs frequently trafficked on the street. The story also reported that some Medicare scammers have stolen the identities of dead physicians to bill Medicare for drugs under the plan.

In addition to requiring valid prescriber numbers, the Carper and Coburn bill would restrict access to the National Provider Registry, a list of physicians and their provider identification numbers that is currently open to the public online. The American Medical Association has long pushed for restricting access to the registry to combat fraud and prevent Internet surfers from stealing physician identities.

The bill includes a number of other anti-fraud provisions, including one that would phase out the so-called “pay and chase” Medicare policy, in which the government checks claims for fraud only after the claim is paid, which often allows fraudsters to stay one step ahead. Instead, the bill would require the Centers for Medicare and Medicaid Services to perform prepayment checks before paying providers.