Medicare fraud: CMS wants to move away from 'pay and chase'

BALTIMORE - Fingerprinting and criminal background checks of HME providers are two of the screening tools that CMS plans to use to crack down on Medicare fraud.

CMS officials laid out these tools and others on Sept. 17 as part of proposed regulations for implementing anti-fraud provisions included in the Affordable Care Act.

"These are important new tools that will help us move from the 'pay and chase' approach that we've been using to one that makes it harder to commit fraud in the first place," said Donald Berwick, CMS administrator, during a Sept. 20 conference call.

Under the proposed rules, all providers would be divided into three risk categories: low, moderate and high. Existing HME and home healthcare providers fall into the moderate-risk category, while new HME and home healthcare providers that are not publicly traded fall into the high-risk category.

"The criteria really had to do with recent experience and documentation of problems in those areas, as well as studies that have come from the Office of Inspector General and the Government Accountability Office," said Peter Budetti, deputy administrator for the Center for Program Integrity.

The proposed rules would also:

* suspend payments when a "credible allegation" of fraud has been made;

* impose a temporary moratorium on enrollments when necessary;

* allow increased, unannounced site visits; and

* use technology to identify potential problems with billing patterns.

Many of the proposed tools are in line with what AAHomecare has proposed in its 13-point fraud plan. Still, stakeholders remain leery of giving CMS authority that is too broad.

"I think it is sort of disconcerting that things could be implemented in a way that hurts legitimate providers who are just trying to run their businesses and treat patients," said Stacey Harms, manager of government affairs for AAHomecare.

Budetti promised that the agency would be "thoughtful" in how its new authority was implemented, including working with the OIG on how best to implement payment suspensions and other provisions.

Last week was a busy one for anti-fraud discussions. On Wednesday, the Health Subcommittee of the Energy and Commerce Committee held a hearing that focused on high-risk areas of Medicare fraud.

AAHomecare President Tyler Wilson attended the hearing, but he didn't testify.

"CMS has done a lousy job of 'locking the door' to keep criminals from bilking all parts of Medicare," he stated in a release after the hearing. "We hope that legislation is enacted and CMS quickens its efforts so that the criminals are stopped."