Amtrak at risk of medical claim fraud, OIG finds

For Immediate Release

December 13, 2019

WASHINGTON – Amtrak continues to have gaps in its controls to effectively identify potentially fraudulent billing patterns in the medical claims it pays, which puts the company’s funds at risk, a new Amtrak Office of Inspector General report released Thursday found.

Amtrak has experienced a number of health care fraud losses. Since 2014, the OIG’s investigative arm has supported multiple investigations that have identified more than $9.5 million in payments the company made to fraudulent medical service providers. The OIG’s previous audit of Amtrak’s medical claims payments found that 14 percent of medical claims submitted between 2013 and 2015 were potentially fraudulent.

At that time, the OIG recommended that Amtrak obtain its own capability to assess its claims for potential fraud and require its claim administrators to put in place fraud detection controls that were tailored to Amtrak’s medical plan. However, Amtrak has yet to obtain that capability, which has resulted in continued gaps in Amtrak’s ability to identify potentially fraudulent medical claims.

For example, in examining Amtrak’s medical claim payments to non-hospital facilities between 2014 and 2018, OIG analysts identified 191 facilities with billing patterns indicative of potential fraud. Amtrak did not identify any concerns with the billing patterns. Because the company is self-insured and pays medical claims from the company’s operating fund, this puts the $57 million paid for these claims at risk of fraud, the report said.

In addition to its previous recommendations to bolster its ability to mitigate fraud risks, the OIG recommended Amtrak implement fraud awareness initiatives to help employees better recognize and report potential fraud, and continually gather information on fraud schemes and trends to better target its fraud monitoring efforts. The OIG also recommended Amtrak review claims paid to the 191 facilities with suspect billing patterns and work to recover any funds in paid claims found to be fraudulent.

More details are available in the full report, located on the OIG’s website:

https://go.usa.gov/xpd6r