Medicare Fraud and Abuse Efforts to Expand Medicare Fraud and Abuse Efforts to Expand Washington Report: Capitol Associates The Centers for Medicare and Medicaid Services (CMS) issued proposed rules, soliciting public input on the development of new efforts to combat fraud and abuse in the Medicare program. HBMA and many other organizations submitted comments in response to the request. While pointing out the organization’s long support for efforts to combat fraud and abuse, HBMA noted, “that in our zeal for preventing fraud and abuse we do not embrace policies that make it more costly for providers to submit legitimate claims for services rendered to Medicare and Medicaid patients.” HBMA went on to note that eliminating fraud and abuse from the Medicare, Medicaid and S-CHIP programs ensures that there are sufficient funds to pay the legitimate claims of physicians and other providers of services. However, HBMA also cautioned CMS that establishing anti-fraud and abuse policies that are onerous to legitimate providers will discourage participation in both the Medicare and Medicaid programs and could result in less access to care by Medicare and Medicaid patients. CMS proposes to establish three levels of risk categories corresponding to the potential for fraud by each category of provider or supplier: Limited, Moderate and High. HBMA agreed that different providers should be treated differently to reflect the relative risk associated with that provider category. Regardless of their status, CMS proposes to subject all provider types to: Verification of any provider/supplier-specific requirements established by Medicare. Conduct license verifications (may include licensure checks across states). Database Checks (to verify Social Security Number (SSN), the National Provider Identifier (NPI), the National Practitioner Data Bank (NPDB), licensure, an OIG exclusion, taxpayer identification number, tax delinquency, death of individual practitioner, owner, authorized official, delegated official, or supervising physician) Providers classified as “Limited Risk” would only be subject to the above standards or checks. Providers deemed a greater risk (classified as “Moderate”) would be subject to unannounced visits. Finally, those providers deemed to be the greatest risk of fraud (classified as “High”) would be subject to all of the above tests, as well as criminal background checks and fingerprinting. HBMA endorsed this type of tiering, although the organization’s comments did raise questions about the classification of some providers. CMS expects to announce the new Fraud and Abuse rules in mid-2011. At this point, it appears that most of the new requirements will apply to providers newly enrolling in the Medicare program. Previous Next