Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

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Provider Enrollment Restrictions Target Medicare Fraud in 6 States

CMS expanded provider enrollment restrictions in six states and implemented stricter screening requirements to combat Medicare fraud.

By Jacqueline LaPointe

- To further prevent Medicare fraud, CMS has extended temporary provider enrollment restrictions in six states and expanded the prohibition’s reach statewide, the federal agency reported on its website.

CMS aims to prevent Medicare fraud by prohibiting provider enrollment in six states

“CMS is continuing its efforts to tackle fraud, waste, abuse and protect benefits and services for those eligible for federal healthcare programs through expanding the existing temporary moratoria,” said Shantanu Agrawal, MD, Deputy Administrator for Program Integrity. “CMS is also increasing its oversight efforts through the use of heightened screening and investigative tools for new providers in the moratoria areas.”

In six states, the provider enrollment moratoria will apply to Medicaid and CHIP services as well as Medicare, which was the focus for the initial prohibition.

The federal agency also granted a six-month extension of the provider enrollment restrictions on home health agencies in Florida, Texas, Illinois, and Michigan The healthcare fraud prevention program has also been implemented statewide.

New Medicare Part B non-emergency ground ambulance suppliers in New Jersey, Pennsylvania, and Texas also face a six-month extension and a statewide expansion.

READ MORE: GA Dentist Sentenced to Prison for $1M Medicaid Fraud Scheme

CMS developed the moratoria in July 2013 to prevent enrollment of new home health agencies and Part B ground ambulance suppliers in specific areas of four states. The provider enrollment restrictions have been renewed at six-month intervals and remain in place in all the original locations.

However, the federal agency recently identified several operational concerns with the enrollment prohibitions because of geographic restrictions. The healthcare fraud prevention initiatives did not stop providers and suppliers from establishing new locations or creating a new enrollment and moving it into a moratorium location.

The programs were also unable to prevent existing suppliers and providers from outside the covered areas from providing services to beneficiaries within the moratorium boundaries. CMS found that “providers and suppliers who are located several hundred miles outside of a moratorium area are billing for services provided to beneficiaries located within that moratorium area.”

To better enforce the moratoria, CMS broadened the anti-fraud initiatives to encompass the entire state and applied the restrictions to other federal healthcare programs.

In effort to support the expansions, CMS also implemented the Provider Enrollment Moratoria Access Waiver Demonstration (PEWD), which allows for some provider and supplier enrollment exceptions and imposes stricter screening measures.

READ MORE: HHS, DoJ Recovered $3.3B From Healthcare Fraud Cases in 2016

“The statewide expansion of the temporary moratoria coupled with the PEWD will allow CMS to continue to target fraud within these services while granting individual enrollment waivers,” the federal agency stated. “These changes will address access to care issues and allow providers and suppliers who are subject to the moratoria to enroll in Medicare, Medicaid, and CHIP after passing heightened screening requirements.”

Program exceptions and waivers will be granted based on beneficiary access to care and if a provider or supplier passes enhanced screening measures.

Under PEWD, CMS also has the authority to restrict the billing of newly enrolled providers to a certain county-based area depending on beneficiary need.  Providers and suppliers are limited to servicing beneficiaries in their designated area and any claims outside of the service area will be denied.

Additionally, the federal agency removed the current temporary moratoria on all Medicare Part B, Medicaid, and CHIP emergency ground ambulance suppliers.

CMS intends for the moratoria and PEWD to contribute to program integrity efforts to save federal healthcare programs from improper payments. Program integrity activities have already saved Medicare $21.1 billion in the 2013 fiscal year and $18.1 billion in the 2014 fiscal year. The savings represent a $12.4 to 1 two-year return on investment.

READ MORE: OIG Releases Healthcare Fraud Compliance Program Guidelines

The recently announced Medicare fraud prevention initiatives are also part of the federal agency’s new proactive strategy. Rather than a “pay and chase” approach, CMS aims to identify potential improper payments before providers receive reimbursements, prevent fraudulent providers and suppliers from enrolling in Medicare and Medicaid, remove wrongdoers from federal healthcare programs, and correct improper reimbursements as quickly as possible.

PEWD and the enrollment moratoria will join other CMS-sponsored anti- fraud initiatives, such as the Fraud Prevention System.

In June, CMS announced that its Fraud Prevention System saved nearly $1.5 billion by using predictive analytics to identify fraudulent claims and illegitimate Medicare payments. The tool searched through 4.5 million Medicare pre-paid claims each day to pinpoint possible payment issues before funds were released.

The various CMS-run healthcare fraud prevention programs are designed to protect federal healthcare programs from unnecessary financial losses, reported CMS in the most recent announcement.

CMS reported that it remains dedicated to protecting “the Trust Funds and other public resources against losses from fraud, waste, abuse, and other improper payments and to improve the integrity of the federal health care system.”

Dig Deeper:

Using Big Data in the Hunt for Healthcare Fraud, Waste, and Abuse

Key Ways to Improve Claims Management and Reimbursement in the Healthcare Revenue Cycle


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