More Site Visits, Data Exposure Will Deter Fraud, CMS Says

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By Michael D. Williamson

Feb. 22 — The Medicare program is taking new steps to screen out potentially fraudulent health-care providers and is releasing data to shed light on provider types and areas at a higher risk of fraud.

The CMS is increasing site visits to Medicare-enrolled providers and suppliers and enhancing information technology systems as a way to counter provider fraud.

In addition, it released two public data sets regarding the availability and use of services provided to Medicare beneficiaries by ground ambulance suppliers and home health agencies, as well as a list of fee-for-service providers and suppliers approved to bill the program.

Using data analysis and moratoria on enrolling new providers in certain geographic areas are important tools for the Centers for Medicare & Medicaid Services to combat fraud associated with criminal enterprises, Kathleen McDermott, a Washington-based attorney with Morgan, Lewis & Bockius LLP, told Bloomberg BNA in a Feb. 22 e-mail.

However, it will be a challenge for the CMS to keep a steady balance and assure access to good health-care providers in affected geographic areas, McDermott said.

Site Visits

When enrolling in Medicare, providers and suppliers (including physicians and non-physician practitioners) are required to supply on their application the address where they offer services, Shantanu Agrawal, the CMS deputy administrator and director of the agency's Center for Program Integrity, wrote in a Feb. 22 CMS blog posting. He said the CMS has the authority, when deemed necessary, to perform on-site reviews of a provider or supplier to verify that the enrollment information is accurate.

Under this authority, the CMS is increasing site visits to providers and suppliers with high reimbursements by Medicare that are located in high-risk geographic areas, Agrawal said.

The CMS is also using enhanced address verification software to better detect vacant or invalid addresses. The CMS also plans to monitor and identify potentially invalid addresses on a monthly basis through additional data analysis by checking addresses against a U.S. Postal Service database, Agrawal said.

The CMS also plans to deactivate certain providers and suppliers that haven't billed Medicare in the last 13 months. Deactivation will begin in March and will remove providers and suppliers with potentially invalid addresses without requiring site visits, Agrawal said.

Data Tool

The agency released the Moratoria Provider and Supplier Services and Utilization Data Tool. The tool uses ambulance and home health agency paid claims data within CMS systems for Medicare fee-for-service beneficiaries, Agrawal said in a separate Feb. 22 blog post.

For this first release, the data provide information on the number of Medicare ambulance suppliers and home health agencies serving a geographic region, with moratoria regions at the state and county level clearly indicated, as well as the number of Medicare beneficiaries who use one of these services.

In January, the CMS announced a six-month extension of temporary enrollment moratoria for new ambulance providers and home health agencies in certain metropolitan areas within six states—Florida, Illinois, Michigan, Texas, Pennsylvania and New Jersey. The extension applies to new enrollments in Medicare, Medicaid and the Children's Health Insurance Program and was imposed due to the ongoing risk of waste, fraud and abuse in the affected metropolitan areas .

Responding to the data release, McDermott said, “It is more effective to use data to focus resources on the more compelling geographic areas rather than taking an overbroad approach with national initiatives that may unfairly snare good providers.”

Since data alone cannot prove fraudulent conduct, the CMS “will want to monitor this effort and test its data theories and address any concerns from good health care providers,” McDermott told Bloomberg BNA.

To contact the reporter on this story: Michael D. Williamson in Washington at mwilliamson@bna.com

To contact the editor responsible for this story: Brian Broderick at bbroderick@bna.com