- The CMS says it will begin taking a more targeted approach to finding and investigating Medicare fraud and improper payments.
- Medicare Administrative Contractors will be instructed to focus on providers with high claim error rates or unusual billing practices when compared to similar providers.
- CMS says the move is building on the Targeted Probe and Educate program it began three years ago to include more provider education during claims reviews. The agency said claims errors have reduced since the program was implemented.
The move away from random selections of providers could help ease the backlog of appeals the agency is working through. CMS expects to have 687,000 pending appeals at the end of this year, and the number is rising. Late last year a judge ordered HHS to clear the backlog by 2021, but the agency said that would be difficult.
In a June 2016 report, the Government Accountability Office (GAO) said reasons behind the backlog likely include the expansion of the Recovery Auditor Program in 2011 and the way appeals of repetitive claims for ongoing services are handled.
That hasn't slowed the Department of Justice, however, which continues to ramp up healthcare fraud investigations, and last month created a task force to focus on fraud within the industry. At around the same time, it announced its largest healthcare crackdown in U.S. history, with charges amounting to $1.3 billion in false claims.
Another GAO report from March questioned the probe and educate method, stating there aren't enough performance metrics to determine whether it is effective. Both reports criticized CMS’ data gathering and analysis efforts.
The program involves reviewing 20 to 40 claims per provider per service for up to three rounds. After each round, providers are given specific education based on the review results.
Dr. Michael Munger, president-elect of the American Academy of Family Physicians, told Modern Healthcare the new model looks like an improvement from the existing approach. “Physicians would only face payment reviews when their billing practices are flagged,” he said.