CMS finalizes anti-fraud rule

by: Charles Fiegl Jan 24, 2011

Federal anti-fraud programs recovered more than $4 billion in fiscal year 2010. HHS, CMS and the Department of Justice (DOJ) stand to recoup more, and prevent further waste and abuse, with new enforcement tools created by a new regulation released today.

Here are three sections in the rule that the federal agencies highlighted today. The final rule (pdf):

Allows for a more "rigorous" screening process for some providers and suppliers enrolling Medicare, Medicaid and CHIP programs. Types of providers and suppliers that have been identified in the past as posing a higher risk of fraud, for example durable medical equipment suppliers, will be subject to a more thorough screening process. Last year's Affordable Care Act exempted most physicians from the rules.
Allows officials to stop enrollment of new providers and suppliers when necessary. Medicare and state agencies will look for trends indicating health care fraud. Officials will use advanced predictive modeling software, such as that used to detect credit card fraud. If a trend is identified in a category of providers or geographic area, the program can temporarily stop enrollment as long as that will not impact access to care for patients.
Creates a mechanism to stop payments to providers and suppliers in cases of suspected fraud. Under the new rules, if there has been a credible fraud allegation, payments can be suspended while an action or investigation is underway.

Blog Tags: anti-fraud

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