CMS Administrator Seema
Verma vows to take 'aggressive actions.'
KEY TAKEAWAYS
A recent study estimated that about 25% of U.S. healthcare
spending is wasteful.
A key element of program integrity for Medicare is to "pay it
right," CMS Administrator Seema Verma says.
A common theme of CMS' new 5-part strategy to combat Medicare
fraud, waste, and abuse is separating honest mistakes from nefarious activity.
The Centers for Medicare & Medicaid Services (CMS) have
announced a five-part strategy to combat
fraud, waste, and abuse in the Medicare program.
About 25% of U.S. healthcare spending is wasteful, according to
a recent article published in
the Journal of the American Medical Association. The JAMA researchers
focused on six categories of waste: failure of care delivery, failure of care
coordination, overtreatment or low-value care, pricing failure, fraud and
abuse, and administrative complexity.
Administrative complexity accounted for the largest amount of
estimated annual wasteful spending at $265.6 billion. Medicare has drawn
criticism for decades over administrative complexity.
In a blog post published last week,
CMS Administrator Seema Verma outlined the agency's five-part "program
integrity strategy."
"CMS defines program integrity very simply: 'pay it
right.' Program integrity must focus on paying the right amount, to
legitimate providers, for covered, reasonable and necessary services provided
to eligible beneficiaries while taking aggressive actions to eliminate fraud,
waste and abuse," Verma wrote.
The five approaches to improve program integrity are stopping bad
actors, preventing fraud, mitigating emerging programmatic risks, reducing
provider burden, and leveraging new technology. Highlights of the strategies
are below.
1. STOPPING BAD ACTORS
Verma says several agencies are actively involved in identifying
Medicare fraud and referring cases to law enforcement, including CMS, the
Office of the Inspector General, the Department of Justice, and Unified Program
Integrity Contractors. "We work with law enforcement agencies to identify
and take action on those who defraud the Medicare program," she wrote.
For example, she says "healthcare fraud takedowns" in
recent months targeting orthotic braces and genetic testing saved Medicare
$3.3 billion dollars.
2. PREVENTING FRAUD
As opposed to Medicare's "pay and chase" model of
combatting fraud in the past, CMS is developing approaches to prevent fraud,
waste, abuse before claims are paid, Verma wrote.
"After we identify bad actors and their schemes, we make
system changes to avoid similar fraudulent activities in the future. CMS'
oversight, audit, and investigative activities allow us to analyze data to
identify potential problem areas. We then work with our law enforcement
partners to develop policies, regulations, and processes to prevent
vulnerabilities from being exploited before claims are paid."
For example, CMS took measures to prevent fraud during the recent
effort to send new Medicare cards to beneficiaries, she wrote.
"CMS implemented an enhanced address validation process to
verify beneficiaries' identities and addresses against multiple information
sources. This ensured that we mailed new Medicare cards to the right person at
the right address. We reviewed over 61 million cards for address accuracy,
which we estimate saved billions of dollars in fraudulent claim payments."
3. MITIGATING EMERGING PROGRAMMATIC RISKS
As Medicare shifts from the program's traditional fee-for-service
payment model to value-based payment models, CMS is committed to developing
safeguards to ensure the integrity of the new reimbursement processes, Verma
wrote.
"New payment models have been very beneficial but also have
the potential to cause new challenges in identifying improper payments,
beneficiary safety issues, and other program integrity concerns. CMS is
continuing to explore ways to identify and reduce program integrity risks
related to value-based payment programs by looking to experts in the healthcare
community for lessons learned and best practices."
4. REDUCING PROVIDER BURDEN
While CMS steps up efforts to combat fraud, abuse, and waste, the
agency is mindful that it should not create inappropriate time and cost burdens
on healthcare providers, Verma says.
"To that end, we have increased efforts to educate providers
in CMS program rules and regulations and remedy onerous processes to assist
rather than punish providers who make good faith claim errors. That's the
purpose of our Targeted Probe and Educate (TPE) program and our efforts to
streamline our recovery audit processes. It's vital to separate providers who
make clerical errors from truly nefarious actors."
Through the TPE program from October 2017 to February 2019, she
says CMS provided one-on-one education for 20,000 healthcare providers and
medical goods suppliers to decrease honest mistakes. "As a result,
approximately 80% of those providers and suppliers were released from further
review," she wrote.
5. DEPLOYING NEW TECHNOLOGY
CMS is committed to deploying new technology to boost the
efficiency of fraud, waste, and abuse reduction efforts, Verma wrote.
"Today, the Medicare fee-for-service program relies on
clinician reviewers—human beings—to review the medical records associated with
items and services billed to Medicare. Providers also have to send us copies of
medical records, which is time-intensive and burdensome. That is why we only
review less than 1% of medical records. Looking forward, CMS is seeking new,
innovative strategies and technologies, perhaps involving artificial
intelligence and/or machine
learning, which are more cost effective and less burdensome to both
providers, suppliers and the Medicare program."
For example, CMS is hoping to upgrade the agency's Fraud
Prevention System and case management systems, she wrote. "While these
systems have helped us to obtain a positive return on investment, we believe
that by adopting cutting edge technology—such as AI and machine learning
tools—we can achieve greater savings for taxpayers and allow us to review more
claims."
Comments on the CMS Center for Program Integrity initiative can be
submitted electronically via email at ProgramIntegrityRFI@cms.hhs.gov. Documents should be submitted in PDF format.
Christopher
Cheney is the senior clinical care editor at HealthLeaders.
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