AAH shares list of fraud-fighting recommendations

WASHINGTON – AAHomecare has shared a list of key recommendations in response to a request for information (RFI) from the Centers for Medicare & Medicaid Services (CMS) on ideas to strengthen the agency’s program integrity efforts. The association will include the recommendations in its comments on the RFI titled “Related to Comprehensive Regulations to Uncover Suspicious Healthcare (CRUSH).” The recommendations: 

• Strengthen provider enrollment requirements for new providers: To prevent fraudulent entities from cycling through the market, AAHomecare recommends implementing a robust identity verification and authentication process to ensure bad actors cannot re-enter under new company names. 

• Improve quality of site visits: There is a critical need to improve the quality of site visits by employing experienced and knowledgeable inspectors. Inaccurate site visits have major consequences, and CMS should review the number of deactivations and revocations that are eventually reinstated to identify systemic issues. 

• Improve cross-program enforcement: If a company’s Medicare Fee-for-Service (FFS) status is revoked, that revocation should be applied across all government healthcare programs, including Medicare Advantage (MA) and Medicaid.  

• Monitor electronic funds transfer (EFT) activity of new suppliers: CMS should monitor EFT activity of new suppliers. When there are large deposits or transfers, those transactions should be flagged and reviewed for any potential suspicious activity. 

• Mandate targeted probe and educate (TPE) on new suppliers: All new supplier locations should be placed in the TPE program to ensure they are compliant from the start. If a new supplier cannot pass TPE after three rounds of education and correction, CMS should consider revocation. 

• Promote electronic orders: CMS should encourage the use of electronic orders as it would improve integration between orders and medical records, communication between providers and suppliers, and will create a digital audit trail, making it easier to identify issues with orders. 

• Leverage technology to review claims in real time: Available technology could enable CMS to review claims as they are submitted. AAHomecare has already engaged CMS to explore a proof of concept where automated review flags concerns and prompts direct beneficiary outreach. 

• Create a CMS tech liaison: A specific liaison position should be created at CMS to coordinate with technology platforms which include industry billing companies and third party technology platforms. These platforms are often the first to see suspicious spikes in activity and need direct contact to report potential fraud.  

• Improve MA oversight: The lack of consistency among the hundreds of MA plans has created confusion within the industry and likely undermined efforts to combat fraud due to the lack of clarity. MA plans should be required to follow all Medicare requirements, including operational, coverage, and payment policies. 

• Expanding prior authorization: CMS should expand the list of HCPCS codes subject to prior authorization to enable review of orders prior to delivery, claim submissions and payment. 

CMS is accepting comments via the Submit a Comment tab near the top of the Federal Register announcement until March 30, 2026.