CMS warns it’s getting tough on crime

December 3, 2014 in Medical Technology

“Bad actors” are the focus of the Centers for Medicare Medicaid Services’ initiative to ramp up oversight of providers and to save taxpayers money.

CMS Administrator Marilyn Tavenner announced the new measures today. They are designed to prevent physicians and other providers with unpaid debt from re-entering Medicare, remove providers with patterns or practices of abusive billing and implement other provisions aimed at saving as much as $327 million a year or more.

“The changes announced today are common-sense safeguards to preserve Medicare for generations to come, while making the rules more consistent for all providers that work with us,” Tavenner said in a press statement. “The Administration is committed to using all appropriate tools as part of its comprehensive program integrity strategy shaped by the Affordable Care Act.”

[See also: CMS called out for EHR fraud failings.]

“CMS has removed nearly 25,000 providers from Medicare, and the new rules help us stop bad actors from coming back in as we continue to protect our patients,” CMS Deputy Administrator and Director of the Center for Program Integrity Shantanu Agrawal, MD, added. “For years, some providers tried to game the system and dodge rules to get Medicare dollars; today, this final rule makes it much harder for bad actors that were removed from the program to come back in.”

CMS is using new authorities created by the ACA to clamp down on Medicare fraud, waste and abuse.

Earlier this year, the Office of the Inspector General put the spotlight on the shortcomings of CMS for failing to dentify and investigate EHR fraud – deficiencies that contributed to the estimated $75 billion to $250 billion in healthcare fraud, according to officials.

[See also: CFO faces 5 years after EHR fraud.]

Today, CMS announced a temporary enrollment moratoria on new ambulance and home health providers in seven fraud hot spots around the country, according to Tavenner. The moratoria are allowing CMS to target its resources in those areas, including use of fingerprint-based criminal background checks, she said, adding that these and other successes continue to protect the Medicare Trust Funds.

CMS has demonstrated that removing providers from Medicare has a real impact on savings, she added. For example, the Fraud Prevention System, a predictive analytics technology, identified providers and suppliers who were ultimately revoked, and prevented $81 million from being paid. 

New changes announced today allow CMS to:

  • Deny enrollment to providers, suppliers and owners affiliated with any entity that has unpaid Medicare debt; this will prevent people and entities that have incurred substantial Medicare debts from exiting the program and then attempting to re-enroll as a new business to avoid repayment of the outstanding Medicare debt.
  • Deny or revoke the enrollment of a provider or supplier if a managing employee has been convicted of a felony offense that CMS determines to be detrimental to Medicare beneficiaries. The recently implemented background checks will provide CMS with more information about felony convictions for high-risk providers or suppliers.
  • Revoke enrollments of providers and suppliers engaging in abuse of billing privileges by demonstrating a pattern or practice of billing for services that do not meet Medicare requirements.
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