CMS drafts new Medicare integrity regulations


The Centers for Medicare & Medicaid Services yesterday released a whopping 678 pages of draft revisions to Medicare C and D regulations intended to fight fraud and save the program about $1.3 billion over five years, The Hill's Health Watch reported.

Further aims of the proposed rule include strengthening beneficiary protections, clarifying program participation requirements, and strengthening the government's ability to spot promising candidates for Parts C and D participation and weed out underperforming contractors.

Here are some of the rule's key provisions:

Consistent with eligibility requirements for Affordable Care Act coverage, CMS proposed adding U.S. citizenship and lawful presence as a requirement to enroll in Medicare Advantage and Medicare Part D plans. The agency also wants to require practitioners prescribing Part D-covered drugs to include an active and valid prescriber National Provider Identifier on prescription drug event records.

The proposed rule would enact an Affordable Care Act provision requiring Medicare Advantage organizations and Part D sponsors to report and return identified Medicare overpayments. It also would strengthen current regulations on Medicare Advantage sponsors' accountability for validating risk adjustment data before submission.  

CMS also wants to change the agent and broker payment structure to reduce incentives to encourage beneficiaries to choose plans that don't meet their healthcare needs. CMS also proposed changes to agent and broker training requirements and limits on referral fees.   

Under the rule, CMS would expand its authority to impose sanctions and civil monetary penalties on Medicare organizations and sponsors. CMS proposed clarifying the scope of its authority to terminate Part C and D contracts when it finds an organization failed to carry out its contract with the government or has performed in a "manner inconsistent with efficient and effective administration," the rule states.

Comments on the draft regulations are due on March 7. If approved, the regulations will take effect next year.  

For more:
- here's the proposed rule
- read the Hill Health Watch article

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