The Affordable Care Act (ACA) gives the government new: resources; rules and sentencing guidelines; penalties; tools to recover overpayments; screening techniques; ways to target high-risk providers and suppliers; and enhanced coordination of fraud-fighting efforts.
Some of the key new tools for preventing fraud are:
• Implementing a more rigorous screening and enrollment process for all providers and suppliers, and having the authority to exclude providers and suppliers who lie on their applications. A company suspended from Medicare or Medicaid in one state will now be suspended on a nationwide basis. The same national penalty will apply to companies suspended from the Children’s Health Insurance Program (CHIP) in a particular state.
• Subjecting those who pose a higher risk to undergo site visits and, in some cases, criminal background checks.
• Suspending payment when there is credible allegation of fraud.
• Imposing a temporary moratorium on newly enrolled providers or suppliers in certain high-risk areas.
• Centralizing claims data to make it easier for agency and law enforcement officials to identify criminals and prevent fraud on a systemwide basis.
• Making compliance programs, with anti-fraud requirements, mandatory for all providers and suppliers.
• Having the authority to impose more stringent payment and enrollment requirements on suppliers and providers of high-risk services or supplies.
• Creating competitive bidding for suppliers of durable medical equipment (DME), a key target of Medicare fraud. DME includes items such as wheelchairs and portable oxygen tanks.
Some of the key new tools for detecting fraud are:
• Implementing predictive models — a combination of data analysis and statistics — to identify patterns of fraud nationwide in real time. The federal government announced in a Department of Health and Human Services press release, dated Jan. 24, 2011, that: “Medicare and state agencies will be on the lookout for trends that may indicate health care fraud — including using advanced predictive modeling software, such as that used to detect credit card fraud. If a trend is identified in a category of providers or geographic area, the program can temporarily stop enrollment as long as that will not impact access to care for patients.”
• These predictive models also help the Medicare Fraud Strike Force identify emerging and migrating Medicare fraud schemes.
• The technology will look at claims to see if there are patterns of unusual activity, such as a surge in particular types of claims in a particular market, or an unusual volume of claims from an individual doctor, hospital or laboratory.
• Conducting onsite visits and criminal background checks for those who have been identified as high-risk suppliers and providers.
• Increasing coordination and sharing of information between government fraud-fighters to deter abusive providers and suppliers from moving their schemes from state to state and sharing data.
• More carefully scrutinizing all high-risk providers’ and suppliers’ activities.
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