Hospitals, ambulance companies share fraud liability burden
Pre-certification programs toe thin line
In December, the Centers for Medicare & Medicaid Services (CMS) launched pre-certification programs in New Jersey, Pennsylvania and South Carolina, requiring pre-authorization for non-emergency transportation in an effort to curb improper Medicare payments. Since then, some patient advocates have raised concerns regarding the line between fraud prevention and access to care. As FierceHealthPayer: AntiFraud previously reported, the program has already forced 11 New Jersey ambulance providers out of business in 2015.
Rather than take a broad approach that handcuffs all providers, McKenna argues that a better strategy would target potentially improper transports to expose nefarious fraud schemes.
"CMS is really struggling on how to combat this type of fraud," he said. "It starts with issuance of the supplier number--but it doesn't have to be black and white, because you can create an access to care situation by implementing some of these rules and regulations."
In other parts of the country, CMS instituted a moratorium on new enrollments for ground ambulance providers in an effort to curb abuse in historically high-fraud areas. Both the moratorium and the pre-certification program offer valuable financial metrics that CMS can bring to Congress. For that reason, it's likely that CMS will continue expanding these programs in high-risk areas.
Unfortunately, these regulations often hinder honest providers, particularly when they seek expansion. For that reason, McKenna favors more rigorous enforcement of flagrantly fraudulent providers.
"Focusing on those unscrupulous providers and suspending them can be an effective way to reduce the amount of dollars going out for improper services," he said.