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ADVANCE Perspective: Physical Therapy & Rehab Medicine

CMS Takes Fraud Fight to a New Level

Published October 13, 2008 11:13 AM by Lauren Fritsky

Last week, the Centers for Medicare & Medicaid Services (CMS) announced a new plan to expand their controversial recovery audit contractor (RAC) program nationally in order curb fraud and abuse in the Medicare system. As of Oct. 1, four new RACs will review paid claims for all Medicare Part A and B claims in designated geographic regions to identify over- and underpayments.

CMS is also targeting home health agencies in Florida and suppliers of durable medical equipment, prosthetics and orthotics (DMEPOS) in that state, along with California , Texas , Illinois , Michigan , North Carolina and New York. The agency plans to:

 

·     Conduct 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;

·     Make unannounced site visits to double check that suppliers and home health agencies are actually in business;

·     Implement extensive pre- and post-payment review of claims submitted by suppliers, home health agencies and ordering or referring physicians;

·     Validate claims submitted by physicians who order a high number of certain items or services by sending follow-up letters to these physicians;

·     Verify 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;

·     Identify and visiting high risk beneficiaries to ensure they are appropriately receiving the items and services for which Medicare is being billed. 

The increased enforcement comes after CMS reported that a 3-year demonstration program in six states recovered more than $900 million in overpayments to health care providers. It includes a focus on billing trends and patterns that may indicate abuse and a stricter review of home health agencies and suppliers of DMEPOS in certain states.

What do you think of the RAC program and CMS’ other efforts to fight fraud?

posted by Lauren Fritsky

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