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."