New tools to fight Medicare fraud

CMS proposes new regulations to strengthen fraud prevention efforts

The Affordable Care Act provides tools to help prevent fraud, waste and abuse in Medicare, Medicaid and the Children’s Health Insurance Program (CHIP).  Today, CMS is proposing new regulations to implement some of the Affordable Care Act’s most significant anti-fraud provisions.

Using the new tools in the Affordable Care Act, CMS will be able to identify and stop fraud on the front end, keeping unscrupulous actors out of the programs to begin with. More stringent enrollment screening requirements, improved data sharing, and the ability to suspend payments where there is credible allegation of fraud are some of the key new tools. The goal of these new tools and authorities is prevention, using new technologies and methods to stop fraud before it starts instead of paying claims now and chasing down criminals later. These new activities will not disrupt business for legitimate providers, and will not disrupt beneficiary access to needed services. 

The Centers for Medicare & Medicaid Services (CMS), the agency in the Department of Health and Human Services that administers these health insurance programs, is using new authorities under the Affordable Care Act to transition its anti-fraud activities from a pay and chase model to a new focus on fraud prevention.  Pay and chase has been a traditional approach for CMS to identify and attack fraud, waste and abuse - generally identifying fraud after a claim has been paid.  Under this approach, unscrupulous individuals could sign up to bill Medicare or Medicaid, receive payments, and CMS subsequently would detect, or chase, overpayments or fraudulent bills and seek recoveries. 

New Tools in the Affordable Care Act: The new and strengthened provisions outlined in these  rules will help to assure that only legitimate and qualified providers and suppliers are enrolled in Medicare and Medicaid, and that only legitimate claims will be paid.  CMS new proposed rules:

1. Enhance and outline the rules for suspending payments to suppliers and providers when fraud is suspected;
2. Establish the authority to deny providers and suppliers the opportunity to enroll in and bill the Medicare, Medicaid, and CHIP programs when necessary to help prevent or fight fraud, waste, and abuse;
3. Strengthen and build on current provider enrollment rules to ensure potential providers and suppliers are appropriately screened according to the risk of fraud, waste, and abuse before being allowed to enroll in and bill Medicare, Medicaid and CHIP;
4. Outline requirements for States to terminate providers from Medicaid and CHIP when terminated by Medicare or another State Medicaid program or CHIP;
5. Authorize CMS to terminate providers and suppliers from Medicare when terminated by a State Medicaid program; and
6. Solicit input on how best to structure and develop provider compliance plans, now required under the Affordable Care Act, that will ensure providers are aware of and comply with CMS program requirements.

Posted: September 21, 2010