Spotlight

Spotlight

Learn more about our recent work and accomplishments.

Image Depicting the Open Payments Video
Open Payments – New Feature Video

Open Payments has released a new, short video to show how Open Payments works, what’s in the data, and how to use the search tool.

Open Payments is a national disclosure program that promotes a transparent and accountable health care system by making the financial relationships between the health care industry and health care providers available to the public. To date the Open Payments data houses more than 76 million records accounting for $53.01 billion of payments or transfers of value.

Check out the video to learn more!

 
Image Depicting Artificial Intelligence
Sources Sought Notice
Using Advanced Technology in the Medical Review Process

As part of the Centers for Medicare & Medicaid Services’ (CMS) commitment to safeguarding taxpayer funding, a Sources Sought Notice (SSN) notice was released to identify companies that are capable of—and interested in—CMS’ efforts to use artificial intelligence technologies to assist in the Medicare fee-for-service medical review process. This SSN was released November 10, 2020 as a follow-up to the Advanced Technology in Program Integrity Request for Information that was released in October 2019.

In the notice, CMS’ program integrity efforts are focused on paying the right amount, to legitimate providers and suppliers, for covered, reasonable and necessary services provided to eligible beneficiaries while taking aggressive actions to eliminate fraud and abuse. CMS is committed to protecting the resources entrusted to our nation’s public health care programs while also protecting the health and well-being of beneficiaries.

Responses to the SSN will be accepted through December 21, 2020.

View the SSN.

 
Image Depicting Telehealth
National Health Care Fraud and Opioid Takedown Results in Charges Against 345 Defendants Responsible for More than $6 Billion in Alleged Fraud Losses

On Sept. 30, the Department of Justice, in coordination with FBI, OIG, and DEA, announced a historic nationwide enforcement action involving charges against 345 defendants across 51 federal districts. The defendants—including more than 100 doctors, nurses, and other licensed medical professionals—have been charged with submitting more than $6 billion in false and fraudulent claims to federal health care programs and private insurers.

The Centers for Medicare & Medicaid Services Center for Program Integrity (CPI) separately announced that it has taken a record-breaking number of administrative actions related to fraud, revoking Medicare billing privileges for 256 additional medical professionals for their involvement in telemedicine schemes.

Under the leadership of Administrator Seema Verma, the CPI team has an ongoing collaboration with law enforcement to continue delivering on the agency’s commitment to protect taxpayer dollars and encourage the prosecution of health care fraud schemes involving telemedicine, durable medical equipment and other illegal behavior. Through CMS’ enforcement alliance with the Health Care Fraud Strike Force, more than 4,200 defendants that collectively billed the Medicare program for about $19 billion in fraudulent payments have been charged since March 2007.

Watch the takedown video.

Read the press release.

 
Annual Wellness Visit
Coverage of an Annual Wellness Visit

This video was created to emphasize the differences between an Initial Preventive Physical Examination (IPPE), Routine Physical Exam (RPE), and Annual Wellness Visit (AWV). The video provides health care professionals with guidance to understand expectations and requirements when submitting documentation for Annual Wellness Visits (AWV) for Medicare beneficiaries.

Watch the video.

For more information about health risk assessments, coding, diagnosis, billing, and initial and subsequent components of an Annual Wellness Visit, visit the MLN Matters booklet Annual Wellness Visit, on the CMS website. This article can be found at MLN Matters® booklet (PDF).

 
image of medical professionals walking
Changes are Coming to Open Payments

Open Payments is a national disclosure program that promotes transparency in the health care industry by making information about the financial relationships between pharmaceutical companies and medical device manufacturers (reporting entities) and physicians and teaching hospitals (covered recipients) available to the public.

Starting in 2021, the type of data collected for Open Payments will expand to include:

  • Five new provider types (in addition to physicians and teaching hospitals): physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists and anesthesiologist assistants, and certified nurse midwives.
  • Three new categories for describing the nature of payments: debt forgiveness, long-term medical supply or device loan, and acquisitions.
  • Reporting requirements for the ‘device identifier’ component of the unique device identifier for medical supplies and devices.

The key dates to be aware of for these changes are:

  • January 2021: Reporting entities begin collecting data that reflects these changes, including information on certain transactions between reporting entities and the newly-added covered recipient groups. Data collection continues for the duration of the year.
  • February and March 2022: Reporting entities submit data from calendar year 2021 to Open Payments.
  • April to mid-May 2022: Covered recipients, including the newly-added covered recipients, have the opportunity to review data reported about them before it is published and dispute it if necessary.

To prepare, learn more details about these changes for reporting entities and covered recipients and sign up for updates on the Contact Us page.

 
Image of doctor at computer
Identifying Physician Owned Distributorships for the Open Payments Transparency Program
Promoting Transparency by holding the healthcare industry accountable for providing the public with physician ownership information.

Open Payments promotes transparency in healthcare by requiring that privately held pharmaceutical and medical device companies report ownership and investment interests held by physicians or their family members. This applies to many Physician-owned distributors (PODs), physician-owned entities that manufacture or sell medical products. To address suspected underreporting by PODs, in September 2019, the Open Payments Program wrote to approximately 35,000 urologists and ophthalmologists reminding them about reporting requirements for physician-owned distributors. Analysis of the most recent data publication showed 122 new ownership records associated with 97 physicians, totaling $26,945,044. To search the data and learn more about Open Payments please visit the Open Payments search tool.

 
Genetic Testing Fraud, Waste, & Abuse
Just Released: Fraud, Waste, and Abuse in Genetic Testing Services White Paper

The Healthcare Fraud Prevention Partnership (HFPP) released its newest White Paper, “Genetic Testing: Fraud, Waste, and Abuse (PDF)” in collaboration with Stanford University School of Medicine. This new HFPP paper provides an overview of clinical genetic testing services, examines fraud, waste, and abuse schemes in the field of genetic testing, and presents possible action that payers can take to address this issue. Overall, the paper intends to help HFPP Partners and other stakeholders guide their own efforts to address systemic vulnerabilities related to fraudulent or abusive genetic testing.

For more information please see:

To learn more about the HFPP, please visit cms.gov/hfpp

 
Program Integrity Knowledge and Resource Center
Learn about calculating overpayments with the latest CPI training
The new Extrapolation/Estimation eLearning course will help you estimate overpayments

The Extrapolation/Estimation course, intended primarily for statisticians and adjudicators, provides instruction based on the new Program Integrity Manual (PIM) 8.4 (PDF) guidelines and focuses on the methodology for calculating an estimation of overpayment. This training is designed to help you interpret CMS policies and procedures consistently with others doing the same work.

Take the Extrapolation and Estimation eLearning course now.

 

Stay Up to Date with CPI

Connect with CPI as we host or attend various events throughout the year, join our mailing list to stay informed on Program Integrity news, or find the most appropriate vehicle to report suspected fraud, waste, or abuse.

Page Last Modified:
03/04/2021 10:00 AM