CMS Announces Medicare Fraud Crackdown

Last month, the Centers for Medicare and Medicaid Services announced that they will be introducing changes to increase security in an effort to reduce cases of Medicare fraud. Prompted in part by the Affordable Care Act, these program updates are centered on making the rules across providers more consistent for providers across the board. Additionally, the intended outcome will ensure the maintained integrity meant to ensure the longterm viability and preservation of Medicare.

What Does the Medicare Fraud Crackdown Mean for Providers?

According to CMS Deputy Administrator and Director of the Center for Program Integrity Shantanu Agrawal, MD, “CMS has removed nearly 25,000 providers from Medicare, and the new rules help us stop bad actors from coming back in as we continue to protect our patients.” These changes give the CMS expanded oversight that could lead to an estimated savings of $327 million on an annual basis.

For providers, suppliers or owners working with Medicare recipients, these changes could mean denied or revoked enrollment. This is not an arbitrary decision however. Those affiliated with entities with outstanding Medicare debts will be denied until the outstanding balance has been paid, or a repayment plan has been put into place. A new background check program will work to identify managing employees with a related felony conviction. Abuse of billing privileges can also result in revoked enrollments. “For years, some providers tried to game the system and dodge rules to get Medicare dollars; today, this final rule makes it much harder for bad actors that were removed from the program to come back in,” said Agrawal.

New challenges brought about by the introduction of electronic health records (EHRs) cost as much as $250 million according to some officials. “The changes announced today are common-sense safeguards to preserve Medicare for generations to come,”  said Administrator of the Centers for Medicare and Medicaid Services, Marilyn Tavenner. For those providers who work within the intended guidelines of Medicare, these new guidelines should mean very little. For those who operate fraudulent practices, however, these changes will make it much more difficult to get fraudulent claims through the system.

Read more about these changes from the CMS. View a comprehensive fact sheet here.