The U.S. Department of Health and Human Services has issued the new rules, set forth by the Affordable Care Act, with the intent fight waste, fraud and abuse in Medicare, Medicaid and the Children’s Health Insurance Program (CHIP).
Click HERE to read the proposed rules.
“These important provisions of the Affordable Care Act will not only help us crack down on criminals who are seeking to scam the system, but will also help us to save millions of taxpayer dollars in Medicare, Medicaid and CHIP—three vital programs that more than 100 million Americans count on for their health care.” said HHS Secretary Kathleen Sebelius. “Using these new fraud prevention measures, CMS will be able to move from a ‘pay and chase’ approach to one that makes it harder to commit fraud in the first place.”
HHS has also recently created a Center for Program Integrity at CMS that is focused on identifying and stopping fraud and acting swiftly to protect beneficiaries.
“While the majority of healthcare providers and suppliers are honest, we also know there are criminals who are looking for any opportunity to take advantage of beneficiaries and rip off Medicare, Medicaid, and CHIP” said CMS Administrator Donald Berwick, MD. “Thanks to the new law, we will now have resources that will enable us to do more to prevent fraud and stop criminals from getting into the system in the first place."
The Affordable Care Act includes new provider screening and enforcement measures to prevent and fight fraud. In addition, the proposed rule contains important new authority to suspend payments when a credible allegation of fraud is being investigated.
Specifically, the proposed rule will:
- Establish the requirements for suspending payments to providers and suppliers based on credible allegations of fraud in Medicare and Medicaid;
- Establish the authority for imposing a temporary moratorium on Medicare, Medicaid, and CHIP enrollment on providers and suppliers when necessary to help prevent or fight fraud, waste, and abuse without impeding beneficiaries’ access to care
- Strengthen and build on current provider enrollment and screening procedures to more accurately assure that fraudulent providers are not gaming the system and that only qualified healthcare providers and suppliers are allowed to enroll in and bill Medicare, Medicaid and CHIP;
- Outline requirements for states to terminate providers from Medicaid and CHIP when they have been terminated by Medicare or by another state Medicaid program or CHIP;
- Solicit input on how to best structure and develop provider compliance programs, now required under the Affordable Care Act, that will ensure providers are aware of and comply with CMS program requirements.
“The rules proposed today are an historic step toward a new era in program integrity,” said Peter Budetti, director of CMS’ new Center for Program Integrity. “We encourage input and feedback on this proposed rule to guide the implementation of the final regulations.”
