Fact Sheets


Details for: CMS PROPOSES NEW SAFEGUARDS AND INCENTIVES TO REDUCE MEDICARE FRAUD



For Immediate Release: Wednesday, April 24, 2013
Contact: CMS Media Relations
202-690-6145


CMS PROPOSES NEW SAFEGUARDS AND INCENTIVES TO REDUCE MEDICARE FRAUD

On April 24, 2013, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would increase incentives for people to report information that leads to a recovery of funds from individuals and entities that have or are engaged in Medicare fraud and abuse. This proposed rule would also improve CMS’ ability to detect new fraud schemes, and help ensure that fraudulent entities and individuals do not enroll in or stay enrolled in Medicare. 

 

This fact sheet summarizes CMS’s proposed changes for the Medicare Incentive Reward Program as well as new provider enrollment provisions outlined in the proposed rule.

 

SUMMARY OF THE INCENTIVE REWARD PROGRAM PROPOSALS

 

CMS is proposing to increase the potential reward amount for information that leads to a recovery of Medicare funds from 10 percent to 15 percent of the final amount collected. The current program caps the reward at $1,000, meaning CMS pays a reward on the first $10,000 it collects as a result of a tip. CMS is also proposing to increase the portion of the recovery on which CMS will pay a reward up to the first $66 million recovered – this means an individual could receive a reward of $9.9 million if CMS recovers $66 million or more.

 

In 1998, CMS began paying rewards to individuals who reported tips that led to the recovery of funds. To date, CMS has recovered approximately $3.5 million as a result of this program and paid just $16,000 for 18 rewards. The proposed changes are similar to the IRS whistleblower program that has resulted in recoveries of over $2 billion since 2003.   

 

 

SUMMARY OF THE PROVIDER ENROLLMENT PROVISIONS

 

Provider enrollment is the gateway to Medicare. CMS routinely evaluates its provider enrollment policies, and has implemented new safeguards as a result of the Affordable Care Act. In the February 2011 final screening rule (72 FR 5862). CMS identified additional changes in enrollment policy that would increase the integrity of the Medicare program. Now, CMS is proposing include the following provisions:

 

  • Add the ability to deny the enrollment of providers, suppliers and owners affiliated with an entity that has unpaid Medicare debt. This proposal would prevent individuals and entities from being able to incur substantial debt to Medicare, leave the Medicare program and then re-enroll as a new business to avoid repayment of the outstanding Medicare debt. We are proposing that CMS would only enroll individuals or entities if they repay the debt or enter into a repayment plan, if they are otherwise eligible for the program.

 

  • Deny enrollment or revoke the billing privileges of a provider or supplier if a managing employee has been convicted of certain felony offenses. This provision ensures that CMS can block or remove bad actors from the Medicare program to protect beneficiaries and safeguard the Medicare Trust Fund.

 

  • Permit CMS to revoke billing privileges of providers and suppliers that have a pattern or practice of billing for services that do not meet Medicare requirements. This proposal is intended to address providers and suppliers that regularly submit inaccurate claims in such a way that it poses a risk to the Medicare program.

 

  • Make the effective date of billing privileges consistent across certain provider and supplier types. Most practitioners and practitioner groups may only submit bills as of the filing date of their enrollment application. CMS is proposing to eliminate ambulance suppliers’ current ability to bill for up to a year prior to enrollment in the Medicare program. CMS is also proposing to require that ambulance providers and other provider and supplier types submit any claims within 60 days of revocation of billing privileges, consistent with the requirements for practitioners and practitioner groups.

 

 

The proposed rule can be downloaded at: https://www.federalregister.gov/public-inspection.

 

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