Detroit Summit Lauds New Fraud Measures

Updated: March 28, 2011

DETROIT — People intent on defrauding Medicare and
Medicaid will find their prospects “a lot gloomier” under
fraud-prevention provisions of the health reform law, Health and
Human Services Secretary Kathleen Sebelius predicted earlier this
month.

Speaking at a regional health care fraud prevention summit in
Detroit March 15, Sebelius and Attorney General Eric Holder
detailed new — and more sophisticated — anti-fraud
tools that the government will use to identify health care fraud,
which sucks billions of dollars out of the system each year.

“Thanks to provisions in the Affordable Care Act, the prospects
for a criminal thinking about targeting our health care system have
gotten a lot gloomier,” Sebelius said. Those provisions took effect
on Friday.

Holder detailed several of the law’s tools to battle fraud,
among them:

• Enhanced screening and other enrollment requirements: As of
  March 25, some categories of providers and suppliers who have
  historically posed a higher risk of fraud or abuse will be screened
  before enrolling in Medicare, Medicaid or CHIP. That includes DME
  suppliers who, whether new or establishing a new location, will
  be considered “high risk.”

  The new rules also allow HHS to impose a temporary moratorium on
  new enrollees of a particular type in certain geographic areas if
  necessary. As well, they authorize CMS to suspend payments to
  providers or suppliers when there is a “credible” allegation of
  fraud.

  Officials have said this will move Medicare away from a “pay and
  chase” mode of having to track down fraudulent payments after the
  fact.

• A focus on compliance and prevention: Under the reform law,
  providers must establish compliance programs and incorporate them
  into their operations. Another new measure requires beneficiaries
  to have a face-to-face visit with the prescriber to receive home
  health and hospice services. According to HHS, “face-to-face
  requirements for DME suppliers and Medicaid providers will be
  issued later this year.”

• Tougher sentences for criminals: The new guidelines increase
  federal sentences for health care fraud by as much as 50 percent
  for crimes involving more than $1 million in losses.

• New resources: Under the law, more than $350 million will be
  pumped into fighting fraud over 10 years. That money will be used
  for increased scrutiny of claims before they’ve been paid,
  sophisticated data analytics and more “feet on the street” law
  enforcement agents.

  The ACA also strengthens coordination among states, CMS, the
  Office of Inspector General and the Department of Justice to stop
  sham providers from moving state-to-state or between Medicare and
  Medicaid. Under the law, states must terminate anyone who has been
  terminated by Medicare or by another state. It also requires CMS to
  work with the OIG on suspending payments to suspect providers and
  allows the agency to give OIG and DOJ real-time data access in
  order to detect fraud schemes.

  In addition, claims data from Medicare, Medicaid and CHIP, the
  Veterans Administration, the Department of Defense, the Social
  Security Disability Insurance program and the Indian Health Service
  will be centralized, making it easier to identify criminals and
  prevent fraud on a system-wide basis.

In a summary of the ACA’s new fraud-fighting provisions on its
HealthCare.gov website, HHS singles out new
requirements for DME suppliers, which it calls “an area of
particular concern when it comes to fraud.”

Along with enhanced Medicare enrollment standards including more
stringent operations and facilities requirements, the agency also
said DMEPOS competitive bidding is one of the tools that will help
battle fraud. But that claim is one the HME industry has long
disputed.

Addressing the issue at the American Association for Homecare
Washington Legislative Conference March 16, Senior Director of
Government Affairs Jay Witter said providers should make sure their
legislators understand the program doesn’t have anything to do with
fighting fraud, which is “a completely different issue.

“Medicare fraud is done by criminals who don’t care how much the
equipment costs,” said Witter. “They aren’t providing it.”