Advocates Urge CMS to Fight Fraud Without Hurting Patients, Providers

CMS/Medicare

WASHINGTON—Organizations representing in-home care and equipment providers responded to the administration’s request for comment on its Comprehensive Regulations to Uncover Suspicious Healthcare (CRUSH) program, saying that fraud fighting efforts are important, but urged administrators to protect patient access and outcomes.

The American Association for Homecare (AAHomecare)’s formal comments said that the Centers for Medicare & Medicaid Services (CMS) should adopt a more nuanced and strategic approach that targets bad actors and risky areas while minimizing the administrative burden on ethical suppliers.

“By working together, we can make strides in ensuring bad actors do not take advantage of the Medicare program while supporting the thousands of legitimate suppliers who are committed to supporting patients in their homes,” AAHomecare President Tom Ryan wrote in a letter to CMS Administrator Mehment Oz dated March 30.

One important move would be to improve the quality of site visits, as many home medical equipment (HME) providers have reported that many of the site inspectors are inexperienced and poorly informed, Ryan wrote.

“Over the last several years, we have heard from our supplier members about their experiences with unknowledgeable and unengaged site inspectors who report inaccurate findings, resulting in supplier locations being revoked,” AAHomeCare’s letter read. “The steep penalties of site visits warrant a requirement for inspectors to be well-informed and committed to providing professional services.”

AAHomecare also recommended: 

  • Implementing a robust identity verification and authentication process to ensure bad actors cannot enter or re-enter the system under new company names.
  • New suppliers should immediately be required to be in a targeted probe and education (TPE), and all audit contractors should operate within their scope of work and coordinate on projects.
  • If a company is revoked from Medicare, the revocation should be applied across all government health care programs and communicated between payers.
  • Expanding electronic ordering, data-sharing capabilities and using CMS’ authority to conduct a proof of concept to implement a real-time verification tool.

The National Alliance for Care at Home (the Alliance) encouraged the agency to continue advancing a targeted, risk-based oversight framework that leverages data analytics, AI and other technology tools to detect and prevent fraud, waste and abuse. The organization said that CMS could also better utilize existing anti-fraud tools, especially in geographic areas or other specific fields where there’s a higher risk of fraud.

“The Alliance and its members have consistently emphasized that CMS’s most effective path to combating fraud is to better leverage and enforce the authorities it already has, rather than creating new administrative requirements that burden compliant providers,” the organization wrote in a 28-page letter to Oz signed by Hillary Loeffler, the Alliance’s vice president for policy and regulatory affairs.

The group recommended that CMS create a home health and hospice program integrity work group with involvement from providers “to develop a comprehensive, risk-stratified set of indicators that paint a complete picture of program risk, identify new and emerging risk factors earlier and align program integrity modernization efforts with provider capabilities.”

The Alliance also recommended CMS should: 

  • Shift oversight dynamically to evolving high-risk areas
  • Use the CMS Market Saturation Dataset—and keep it more updated—to track risk
  • Require new agencies to undergo more frequent surveys and training in high-risk areas 
  • Conduct surveys once a year for the first three years 
  • Require agencies to complete training from Medicare Administrative Contractors each year for the first three years 
  • Require agencies in hospices in targeted areas to go through revalidation every three years rather than every five, and annually for newly enrolling businesses

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