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On August 27, Mark
B. McClellan, M.D., Ph.D., Administrator for CMS announced a
new program to crack down on Medicare and Medicaid fraud and
abuse by using modern electronic tools. CMS is using technology
to identify potential fraud and payment problems much more quickly
and accurately than before, which in turn allows the Centers
to educate providers and recipients about the prevention of
fraud, abuse, and waste. This program will also include fraud
involved with the discount drug card program, the Part D prescription
drug benefit, and the Medicare Advantage Plans. A proposed regulation
was also announced which requires that states report to HHS
incorrect payments in both Medicaid and State Children’s
Health Insurance Programs. |
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HHS will then calculate
a national error rate for every state and Washington D.C. Drug
card activities will also be monitored by IntegriGuard, which
is a Program Safeguard Contractor (PSC) that has a contract
with CMS. Drug pricing information will be monitored weekly,
and another goal of CMS and the PSC is to prevent the creation
of counterfeit cards and identity theft attempts. CMS will also
be focusing on some specific areas of the U.S. that have been
identified as fraud “hot spots”. There has already
been significant success in southern California (which has been
acknowledged as a “hot spot”) in the past year and
a half. CMS will also analyze Medicaid and Medicare claims data
together so that patterns will be recognized that are not always
otherwise detectable when the data is analyzed separately. |
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This part of the program,
referred to as the Medi-Medi project, has had success in California,
Florida, Illinois, New Jersey, North Carolina, Pennsylvania,
and Texas so far. It is being expanded into Ohio and Washington.
CMS is also implementing a pilot project to determine how effective
hospital compliance programs actually are. This pilot will attempt
to conclude whether or not some actions by healthcare providers,
including auditing and monitoring, affect the hospitals’
billings. Guidelines will then be issued based on the findings
and providers will be educated on effective compliance practices.
This program is expanding upon an already existing program,
referred to as Comprehensive Error Rate Testing (CERT). |
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This program has been
successful, as the error rate was 5.8% in 2003, which had been
reduced from 14% in 1996. For the full press release, please
visit: |
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http://www.cms.hhs.gov/media/press/release.asp?Counter=1178 |
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