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CMS upgrades fraud detection tactics through data transparency, increased site visits

Two new federal initiatives take aim at longstanding fraud risks

Data transparency, enhanced provider screening software and additional site visits will serve as key components of the federal government's upgraded approach to fraud detection and prevention, outlined in two new programs announced by the Centers for Medicare & Medicaid Services (CMS) last week.

In response to a 2015 report from the Government Accountability Office that found 22 percent of physicians enrolled in Medicare listed a potentially ineligible address thanks to weaknesses in CMS oversight, the agency announced it will be increasing the number of site visits to providers and suppliers with high reimbursement rates located in geographical areas with statistically high fraud rates, while making enhancements to the Provider Enrollment Chain and Ownership System (PECOS). This year, CMS plans to replace current PECOS address verification software with a Data Point Verification system that flags vacant and invalid addresses, as well as commercial mail reporting agencies or P.O. boxes. Unverified addresses could trigger ad hoc site visits.

Additionally, CMS plans to analyze enrollment data on a monthly basis and deactivate providers that have not billed Medicare within 13 months, which is an approach that will remove providers with an invalid address without resorting to a site visit.

On the same day, CMS released two new public data sets on the utilization of home health and ambulance services and a list of all approved Medicare providers and suppliers that are registered through PECOS. In a blog post, CMS also announced it was extending its moratoria on home health and ambulance providers in certain areas of the country that pose a high risk for fraud. Since 2013, CMS barred new new home health and ambulance providers in high-risk regions from billing Medicare, while periodically expanding the program to other geographical regions.

Utilization data released by CMS includes a color-coded interactive map that categorizes the number of Medicare beneficiaries accessing home health or ambulance services in each state and county. The data also includes information on the number of providers servicing a particular area, and the average number of users per providers. CMS plans to use the information, updated quarterly, to determine which new geographical areas and health services could benefit from a moratorium. 

In 2015, a report released by the Office of Inspector General found one in five ambulance providers submit questionable claims. In addition to barring new providers from billing Medicare, CMS has gone after inappropriate ambulance claims in some areas by implementing preauthorization programs for non-emergency transportation. Earlier this month, CMS released a proposed rule that would allow the agency to collect baseline data on probable fraud payments in the home health industry and launch a preauthorization project in five states.

CMS plans to publically release PECOS data each quarter which will offer "a clear and transparent way for providers, suppliers, state Medicaid programs, private payers, researchers, and other interested individuals or organizations to leverage Medicare Provider Enrollment information." States have previously voiced concerns about access to PECOS data that would help fill gaps in Medicaid enrollment screening.

To learn more:
- here's the CMS release on increased site visits
- read the blog post on home health and ambulance moratoria
- see the CMS fact sheet on home health and ambulance utilization data
- check out the interactive map

Related Articles:
OIG: Medicare paid $30 million for untraceable ambulance rides
CMS drafts new rules to limit home health fraud
CMS extends home health, ambulance moratoria for another six months
GAO to Congress: CMS needs to do more to prevent Medicaid fraud
Medicare physician enrollment screening overlooks questionable addresses, license reviews