CMS Announces New Medicare Program Integrity Strategy

October 23, 2019 | Eric D. Fader | Fraud and Abuse | Home Health | Legislation and Public Policy | Medicare and Medicaid

In an October 21 blog post titled “The Future of Medicare Program Integrity,” Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma described a new five-pronged approach to combat waste, fraud, and abuse in the Medicare program. The five “pillars” of the initiative are:

  • Stop bad actors. CMS works with the Office of Inspector General, Department of Justice and Unified Program Integrity Contractors to identify and prosecute fraud as quickly as possible.
  • Prevent fraud. CMS is focusing on preventing fraud, waste and abuse proactively rather than reimbursing fraudsters for services and attempting to recoup the payments later, an enforcement model colloquially known as “pay and chase.” Among other efforts, the agency will target high-risk areas and attempt to weed out unscrupulous providers and suppliers before they bill the program, as discussed here.
  • Mitigate Emerging Programmatic Risks. “We must be vigilant in monitoring new and emerging areas of risk,” Verma said, referencing increased use of prior authorization requirements and implementing new approaches to “high vulnerability” areas like home health.
  • Reduce provider burden. CMS’s Targeted Probe and Educate program aims to better educate providers on the agency’s rules and regulations and streamline burdensome administrative processes. The hope is that by reducing the incidence of good-faith clerical errors, they can be more easily distinguished from intentional wrongdoing.
  • Leverage New Technology. The agency intends to modernize and automate its program integrity tools using advanced analytics and artificial intelligence.

CMS also released two Requests for Information (RFIs) asking for input from the healthcare community on “The Future of Program Integrity” and “Using Advanced Technology in Program Integrity.” Public comments on both RFIs will be accepted until November 20.

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