The Centers for Medicare & Medicaid Services (CMS) says it is taking "aggressive new steps to find and prevent waste, fraud, and abuse in Medicare." Officials say they are working closer with beneficiaries and providers, consolidating fraud detection efforts, strengthening oversight of medical equipment suppliers and home health agencies, and launching the recovery audit contractor (RAC) program.
"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."
CMS says it is consolidating its efforts with new program integrity contractors that will look at billing trends and patterns across Medicare. They will focus on companies and individuals whose billings for Medicare services are higher than the majority of providers and suppliers in the community. CMS also is shifting its traditional approach to fighting fraud by working directly with beneficiaries to ensure that they received the durable medical equipment or home health services for which Medicare was billed and that the items or services were medically necessary.
Furthermore, CMS will take additional steps to fight fraud and abuse in home health agencies in Florida and by suppliers of durable medical equipment, prosthetics, and orthotics (DMEPOS) in Texas, Florida, California, Illinois, Michigan, North Carolina, and New York. All Medicare contractors including TrailBlazer do extensive analysis of claims data. They look for aberrations in the data that identify states with a potential problem. TrailBlazer Health Enterprises identified DME use in Texas as an outlier several years ago.
The additional steps include:
- Conducting more stringent reviews of new DMEPOS suppliers' applications including background checks to ensure that Medicare has not suspended a principal, owner, or managing owner;
- Making unannounced site visits to double-check that suppliers and home health agencies actually are 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 those 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 the services;
- Identifying and visiting high-risk beneficiaries to make sure they appropriately receive the items and services for which Medicare is billed.
For claims not reviewed before payment, CMS is implementing further medical review of DMEPOS claims by one of the new RACs. The RACs review all Medicare Part A and B paid claims to make sure they meet Medicare statutory, regulatory, and policy requirements and regulations. If the RAC finds any improperly paid Medicare claim, it will request repayment from the provider if an overpayment was found or request that the provider be repaid if the claim was underpaid.
A three-year RAC demonstration program in California, Florida, New York, Massachusetts, South Carolina, and Arizona collected more than $900 million in overpayments and returned nearly $38 million in underpayments. The RAC program is scheduled for expansion to Texas in March.
Action , Oct. 16, 2008