Medicare Getting Tougher on Fraud, Waste, Abuse and
Will Ask for Help from Seniors
New contractors to review paid claims for all
Medicare Part A and B providers to ensure claims meet statutory,
regulatory and policy regulations
Oct.
6, 2008 – After a successful demonstration project recovered over $900
million in overpayments by Medicare, the Centersfor
Medicare & Medicaid Services announced today a program it describes as
“aggressive new steps to find and prevent waste, fraud and abuse in
Medicare." And, you may be called on to help. Or, you may be questioned
by a new national recovery audit contractor.
The effort appears to be aimed primarily at medical
equipment suppliers and home health agencies. CMS says it is going to
maintain a closer direct relationship with beneficiaries to be sure they
received the equipment and services ordered and paid for by CMS.
CMS says working directly with Medicare
beneficiaries is a shift in its traditional approach to fighting fraud.
They will not only communicate with beneficiaries
to ensure they received the durable medical equipment or home health
services for which Medicare was billed, but will also verify that the
items or services were medically necessary.
CMS says it is also working closer with providers,
consolidating its fraud detection efforts, and strengthening its
oversight of medical equipment suppliers and home health agencies.
“Because Medicare pays for medical services and
items without looking behind every claim, the potential for waste, fraud
and abuse is high,” said CMS Acting Administrator Kerry Weems.
“By enhancing our oversight efforts we can better
ensure that Medicare dollars are being used to pay for equipment or
services that beneficiaries actually received while protecting them and
the Medicare trust fund from unscrupulous providers and suppliers.”
National
Recovery Audit Contractors
Another aggressive new change announced today is
the launching the national recovery audit contractor (RAC) program.
CMS will also be using new “program integrity
contractors” that will look at billing trends and patterns across
Medicare. Their focus will be on companies and individuals whose
billings for Medicare services are higher than the majority of providers
and suppliers in the community.
Medicare is required by law to pay claims to health
care providers for services provided to beneficiaries within 30 days
after the claim is submitted, as long as the claim meets Medicare’s
rules. After the claim is paid, CMS or its contractors can review the
claim to ensure that the items or services were actually provided or the
services were medically necessary.
If the claim was not submitted under Medicare’s
rules, CMS checks to see if the claim was submitted in error or may be
potentially fraudulent. Those claims that could be fraudulent are
referred to law enforcement for further investigation.
Targeting Florida Home Health Agencies,
equipment suppliers in some states
CMS also announced it will be taking additional
steps to fight fraud and abuse in home health agencies in Florida and
suppliers of durable medical equipment, prosthetics and orthotics (DMEPOS)
in Florida, California, Texas, Illinois, Michigan, North Carolina and
New York.
These additional steps include:
● Conducting more stringent reviews of new
DMEPOS suppliers’ applications including background checks to ensure
that a principal, owner or managing owner has not been suspended by
Medicare;
● Making unannounced site visits to double check
that suppliers and home health agencies are actually in business;
● Implementing extensive pre- and post-payment
review of claims submitted by suppliers, home health agencies and
ordering or referring physicians;
● Validating claims submitted by physicians who
order a high number of certain items or services by sending follow-up
letters to these physicians;
● Verifying the relationship between physicians
who order a large volume of DMEPOS equipment or supplies or home health
visits and the beneficiaries for whom they ordered these services;
● Identifying and visiting high risk
beneficiaries to ensure they are appropriately receiving the items and
services for which Medicare is being billed.
The additional reviews that will be focused on
DMEPOS equipment and supplies with high expenditures and high growth
rates expect to identify items such as oxygen supplies and equipment,
power mobility devices or power wheelchairs, and diabetic test strips.
For those claims not reviewed before payment is
made, CMS is implementing further medical review of submitted DMEPOS
claims by one of the new RACs.
The RACs review paid claims for all Medicare Part A
and B providers to ensure their claims meet Medicare statutory,
regulatory and policy requirements and regulations. If the RACs find
that any Medicare claim was paid improperly it will then request
repayment from the provider if an overpayment was found or request that
the provider is repaid if the claim was underpaid.
The new RACs were selected under a full and open
competition and will begin to educate and inform providers later in
October and November about the program.
The RACs will be paid on a contingency fee basis on
both the overpayments and underpayments they find. The selection of
these new contractors was based on a best value determination that
included a sound technical approach for the level and quality of claim
analysis and detail to exceptional customer service, conflict of
interest reviews and lowest contingency fee.
The
3-year RAC demonstration program in California , Florida , New York ,
Massachusetts , South Carolina and Arizona collected over $900 million
in overpayments and nearly $38 million in underpayments returned to
health care providers.
Finally, CMS is consolidating the work of
Medicare’s program safeguard contractors (PSCs), and the Medicare Drug
Integrity Contractors (MEDICs) with new Zone Program Integrity
Contractors (ZPICs).
The new contractors will eventually be responsible
for ensuring the integrity of all Medicare-related claims under Parts A
and B (hospital, skilled nursing, home health, provider and durable
medical equipment claims), Part C (Medicare Advantage health plans),
Part D (prescription drug plans) and coordination of Medicare-Medicaid
data matches (Medi-Medi).
The first two ZPIC contracts were awarded to Health
Integrity, LLC for Zone 4 which encompasses Texas , New Mexico ,
Colorado and Oklahoma and SafeGuard Services LLC for Zone 7 which
encompasses Florida , Puerto Rico and US Virgin Islands.
“We are continuing to build on our fraud fighting
and program integrity efforts by identifying high risk areas and trends
to better focus our limited funds and resources,” said Weems.
Oct.
6, 2008 – After a successful demonstration project recovered over $900
million in overpayments by Medicare, the Centers for
Medicare & Medicaid Services announced today a program it describes as
“aggressive new steps to find and prevent waste, fraud and abuse in
Medicare." And, you may be called on to help. Or, you may be questioned
by a new national recovery audit contractor.
National
Recovery Audit Contractors
The
3-year RAC demonstration program in California , Florida , New York ,
Massachusetts , South Carolina and Arizona collected over $900 million
in overpayments and nearly $38 million in underpayments returned to
health care providers.