Medicare Fraud: CMS Announces Increase in Site Visits

02/29/16 5:39 PM PST

CMS steps up measures against Medicare fraud

Overview

The Center for Medicare and Medicaid services has announced in a February 22nd blog post that it will begin increasing the frequency of its site visits. This enforcement is necessary, with fraud estimated by experts to account for around three to ten percent of all healthcare spending. Recent crackdowns on Medicare fraud, partially due to ACA Medicare spending cuts, led to the biggest bust of all time in June of 2015.

CMS will begin their increased site visits by targeting Medicare providers who receive high reimbursements and are located in high-risk areas. This year, CMS is expanding enforcement to better identify fraudulent providers through updated detection abilities. Following are the three new strategies that CMS will use to better detect Medicare fraud:

1) Enhance address verification software to better detect invalid addresses and CRMAs (commercial mail reporting agencies).

2) De-activate providers who have not billed Medicare in the last thirteen months

3) Check monthly for invalid addresses by comparing databases with the U.S. Postal Service.

More details

Below is an excerpt from the original post by Shantanu Agrawal, M.D., CMS Deputy Administrator and Director, Center for Program Integrity on The CMS Blog:

“…When enrolling in Medicare, providers and suppliers (including physicians and non-physician practitioners) are required to supply on their application the address of the location from which they offer services. As a result of our continuous review of policies, we have put into practice four tactics to strengthen strategies designed to reinforce provider and supplier screening activities:

Increase the number of site visits to Medicare-enrolled providers and suppliers. CMS has the authority, when deemed necessary, to perform onsite review of a provider or supplier to verify that the enrollment information submitted to CMS or its agents is accurate and to determine compliance with Medicare enrollment requirements (42 C.F.R. 424.517). Under this authority, CMS has increased site visits, initially targeting those providers and suppliers receiving high reimbursements by Medicare that are located in high risk geographic areas.

Enhance address verification software in PECOS to better detect vacant or invalid addresses or commercial mail reporting agencies (CMRAs). Starting this year, CMS will replace the current PECOS address verification software with new software that includes Delivery Point Verification (DPV) in addition to the existing functionality. This new DPV functionality will flag addresses that may be vacant, CMRAs or invalid addresses. In most cases, CMRAs are not permitted in the Medicare program. These verifications will take place during the application submission process and may trigger additional ad hoc site visits.

Deactivate providers and suppliers that have not billed Medicare in the last 13 months. Beginning March 2016 and on a monthly basis, CMS will run analysis on enrollment data to deactivate providers or suppliers meeting specific criteria that have not billed Medicare in the last 13 months. Providers and suppliers that may be exempted from the deactivation for non-billing include: those enrolled solely to order, refer, prescribe; or certain specialty types (e.g., pediatricians, dentists and mass immunizers (roster billers)). This approach will remove providers and suppliers with potentially invalid addresses from PECOS without requiring site visits.

Monitor and identify potentially invalid addresses on a monthly basis through additional data analysis by checking against the U.S. Postal Service address verification database. CMS has started to continuously monitor and identify addresses that may have become vacant or non-operational after initial enrollment. This monitoring is done through monthly data analysis that validates provider and supplier enrollment practice location addresses against the U.S. Postal Service address verification database…”