- CMS has announced a new rule focused on catching providers before they engage in fraudulent activity.
- The rule, called Program Integrity Enhancements to the Provider Enrollment Process, will focus on untoward "affiliations" involving key employees of companies that bill the Medicare, Medicaid or CHIP programs.
- Of particular interest will be firms that try to "reinvent" themselves and those that have failed to repay prior overpayments — tactics CMS said it had mostly begun using five years prior.
Much of the fraud in government healthcare programs is detected after the fact, when providers acting in bad faith have already been paid tens of thousands, if not millions, of dollars. CMS has pledged to change that practice with the introduction of its new rules.
For example, if a key employee of a firm that bills Medicare, Medicaid or CHIP is determined to have been involved with a firm that previously had their billing authority revoked, CMS can move to bar the new entity from participating in those programs.
"For too many years, we have played an expensive and inefficient game of ‘whack-a-mole’ with criminals — going after them one at a time — as they steal from our programs. These fraudsters temporarily disappear into complex, hard-to-track webs of criminal entities, and then re-emerge under different corporate names. These criminals engage in the same behaviors again and again,” CMS Administrator Seema Verma said in a statement, which did not name any specific repeat offenders. "Now, for the first time, we have tools to stop criminals before they can steal from taxpayers."
Many large providers, such as Sutter Health, have been caught overcharging Medicare, but they typically pay a settlement and continue to participate in the program. Usually only small providers or businesses are barred entirely.
It’s not the first time CMS has tried to proactively clamp down on fraud. During the Obama administration, former agency administrator Marilyn Tavenner introduced a similar program in 2014. It focused on barring providers with unpaid Medicare debts or with a managing employee that had certain felony convictions.
When revamps to the rules were first floated in 2016, the American Hospital Association urged caution that it not penalize providers for "minor administrative errors, and providers should not be held responsible for reporting information that they have no ability to access or verify."