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Medicare & Medicaid News

CMS Takes Another Big Step in Fighting Medicare Fraud, Abuse

CMS says new rules enhance Medicare provider oversight; strengthens beneficiary protections

Medicare and dollar signsDec. 3, 2014 - New rules that strengthen oversight of Medicare providers and protect taxpayer dollars from bad actors were announced today by Marilyn Tavenner, administrator of the Centers for Medicare and Medicaid Services. The new safeguards are designed to prevent physicians and other providers with unpaid debt from re-entering Medicare, remove providers with a pattern or practice of abusive billing and implement other provisions to help save more than $327 million annually.

“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.

 

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“The Administration is committed to using all appropriate tools as part of its comprehensive program integrity strategy shaped by the Affordable Care Act.”

CMS Deputy Administrator and Director of the Center for Program Integrity, Shantanu Agrawal, M.D., said, “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. 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 Affordable Care Act to clamp down on Medicare fraud, waste and abuse.

CMS currently has in place temporary enrollment moratoria on new ambulance and home health providers in seven fraud hot spots around the country. The moratoria are allowing CMS to target its resources in those areas, including use of fingerprint-based criminal background checks.  These and other successes continue to protect the Medicare Trust Funds.

CMS claims it has demonstrated that removing providers from Medicare has a real impact on savings. Cited as an 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.

>>  Read a fact sheet about today’s final rule

>>  The final rule visit

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