CMS clamping down on Medicare fraud

CMS clamping down on Medicare fraud

Over the last four years, the Obama administration has recovered nearly $15 billion in healthcare fraud judgments, settlements, and administrative impositions, according to the Centers for Medicare & Medicaid Services (CMS).

The agency reported on June 6 that it has revoked 14,663 providers and suppliers’ ability to bill in the Medicare program since March 2011. "These providers were removed from the program because they had felony convictions, were not operational at the address CMS had on file, or were not in compliance with CMS rules," the agency said in a news release.

In 18 states, the number of revocations has quadrupled since CMS implemented Affordable Care Act (ACA) screening and review requirements, in addition to proactive data analysis that identifies potential license discrepancies of enrolled individuals and entities. "These efforts are ensuring that only qualified and legitimate providers and suppliers can provide healthcare products and services to Medicare beneficiaries," CMS stated.

The following states had more than 600 revocations in the past two years:

  • Florida - 2,064
  • Texas - 1,417
  • Pennsylvania - 1,077
  • California - 969
  • New York - 790
  • Ohio - 689

In the two years prior to implementation of ACA screening provisions, CMS revoked billing privileges for 6,307 Medicare providers nationwide. During that timeframe only three states -- Florida (874), Texas (703) and California (673) -- had more than 600 revocations.

Additionally, in April of this year, CMS announced a proposed rule that would increase rewards up to $9.9 million paid to individuals whose tips about suspected fraud lead to the successful recovery of Medicare funds. Previous reward amounts topped out at $10,000.

CMS said people covered by Medicare will soon see a redesigned statement of their claims for services and benefits that will help them better spot potential fraud, waste and abuse.

“The new Medicare Summary Notice gives seniors and people with disabilities accurate information on the services they receive in a simpler, clearer way,” said CMS Administrator Marilyn Tavenner in a prepared statement. “It’s an important tool for staying informed on benefits, and for spotting potential Medicare fraud by making the claims history easier to review."

The redesigned notice will make it easier for people with Medicare to understand their benefits, file an appeal if a claim is denied, and spot claims for services they never received, the agency said. CMS will send the notices to Medicare beneficiaries on a quarterly basis.

“A beneficiary’s best defense against fraud is to check their Medicare Summary Notices for accuracy and to diligently protect their health information for privacy,” said Peter Budetti, CMS deputy administrator for program integrity, in a prepared statement. “Most Medicare providers are honest and work hard to provide services to beneficiaries. Unfortunately, there are some people trying to exploit the Medicare system.”