Spotlight

Spotlight

Learn more about our recent work and accomplishments.

Medicare Fee-for-Service Claims
Medicare Fee-for-Service Claims Review When the Public Health Emergency Ends

CMS recognizes that it is important for stakeholders to understand how CMS anticipates performing medical review after the Public Health Emergency (PHE) has ended. Below is an FAQ that addresses how our review contractors (Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs) and the Supplemental Medical Review Contractor (SMRC)) plan to conduct medical reviews post PHE.

Q. At the end of the Public Health Emergency (PHE) how will CMS’ review contractors conduct medical reviews for claims billed during the PHE based on approved waivers or flexibilities?

A. CMS contractors (MACs, RACs, and SMRC) review a very small percentage of Medicare Fee-for-Service claims each year. During the PHE, flexibilities were applied across claim types. For certain DME items, this included the non-enforcement of clinical indications for coverage. Since clinical indications for coverage were not enforced for certain DME items provided during the PHE, once the PHE ends CMS plans to primarily focus reviews on claims with dates of service outside of the PHE, for which clinical indications of coverage are applicable. We note that we may still review these DME items, as well as other items or services rendered during the PHE, if needed to address aberrant billing behaviors or potential fraud. The HHS-Office of the Inspector General may perform reviews as well. All claims will be reviewed using the applicable rules in place at the time for the claim dates of service.

For more information about medical reviews and the claims process, please visit the Medical Review and Education page.

 
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Nationwide Coordinated Law Enforcement Action to Combat Telemedicine, Genetic Testing, and Durable Medical Equipment Fraud and CMS Administrative Actions

On July 20, 2022, the Department of Justice announced criminal charges against 36 defendants in 13 federal districts across the United States for more than $1.2 billion in alleged fraudulent telemedicine, cardiovascular and cancer genetic testing, and durable medical equipment (DME) schemes.

The nationwide coordinated law enforcement action includes criminal charges against a telemedicine company executive, owners and executives of clinical laboratories, durable medical equipment companies, marketing organizations, and medical professionals. In connection with the enforcement action, the department seized over $8 million in cash, as well as luxury vehicles and other fraud proceeds.

Additionally, the Centers for Medicare & Medicaid Services (CMS), Center for Program Integrity (CPI) announced today that it took adverse administrative actions against 52 providers involved in similar schemes.

“The Centers for Medicare & Medicaid Services continues to aggressively investigate fraud, waste and abuse and has taken action to protect patients, critical health care resources and to prevent losses to the Medicare Trust Fund,” said CMS Administrator Chiquita Brooks-LaSure. “Work like this to combat fraud, waste, and abuse in our federal programs would not be possible without the successful partnership of CMS, the Department of Justice, and the U.S. Department of Health and Human Services Office of Inspector General.”

Read the DOJ press release.

 
Healthcare Fraud Prevention Partnership 10th Anniversary
The Healthcare Fraud Prevention Partnership Celebrates 10 Years

This year the Healthcare Fraud Prevention Partnership (HFPP) is celebrating its 10th year as a leader in strengthening the nation’s fight against healthcare fraud, waste, and abuse. The HFPP is a voluntary public-private partnership that helps detect and prevent healthcare fraud through data and information sharing. Partners include federal government, state agencies, law enforcement, private health insurance plans, employer organizations, and healthcare anti-fraud associations.

The Partnership's purpose then and now is to exchange facts and information between the public and private sectors and enable the performance of sophisticated data analytics against our unique cross-payer data set to reduce the prevalence of healthcare fraud. Read the press release from when the HFPP was announced.

The HFPP has come a long way since its inception in 2012. Check out some of the key accomplishments:

  • In 2012, when the HFPP was formed, it consisted of 21 Partners. Driven by the importance and value of the HFPP’s mission, membership has grown over the last 10 years by over 250 members.
  • The HFPP first began with professional claim types only, then expanded in 2019 to include institutional; in 2021, pharmacy claims were added for more comprehensive analytic insights.
  • Starting initially with original claims data, the Partnership is now conducting its analysis against adjusted claims to detect industry-wide fraud schemes more precisely.

Over the next decade and beyond, the HFPP looks forward to continuing its work with Partners to enhance fraud-fighting efforts through innovative initiatives, enhanced study analytics, enriched infrastructure, expanded engagement, increased membership, and strengthened strategic partnerships.

Learn more about the Partnership.

 
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Appalachian Regional Prescription Opioid Strike Force Actions to Combat Unlawful Prescribing Amidst the Continuing Opioid Epidemic

On May 4, 2022, the Department of Justice, together with federal and state law enforcement partners, today announced criminal charges against 14 defendants in eight federal districts across the United States for their alleged involvement in crimes related to the unlawful distribution of opioids. Twelve of the defendants were licensed medical professionals at the time of these alleged offenses.

Additionally, the Centers for Medicare & Medicaid Services’ (CMS) Center for Program Integrity has taken six administrative actions against providers for their alleged involvement in these offenses.

"Patient care and safety are top priorities for us, and CMS has taken administrative action against eight providers to protect critical resources entrusted to Medicare while also safeguarding people with Medicare,” said CMS Administrator Chiquita Brooks-LaSure. "These actions to combat fraud, waste, and abuse in our federal programs would not be possible without the close and successful partnership of the Centers for Medicare & Medicaid Services, the Department of Justice, and the U.S. Department of Health and Human Services Office of Inspector General."

Read the DOJ press release.

 
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COVID-19 Coordinated Law Enforcement Action and CMS Administrative Actions

On April 20, 2022, the Department of Justice announced criminal charges against 21 defendants in nine federal districts across the United States for their alleged participation in various health care related fraud schemes that exploited the COVID-19 pandemic. These cases allegedly resulted in over $149 million in COVID-19-related false billings to federal programs and theft from federally-funded pandemic assistance programs. This announcement builds on the success of the DOJ’s May 2021 COVID-19 Enforcement Action and involves the prosecution of various COVID-19 health care fraud schemes.

Additionally, the Center for Program Integrity, Centers for Medicare & Medicaid Services (CPI/CMS) separately announced today that it has taken an additional 28 administrative actions against providers for their alleged involvement in fraud, waste and abuse schemes related to the delivery of care for COVID-19, as well as schemes that capitalize upon the Public Health Emergency.

“We are committed to working closely with our law enforcement partners to combat fraud, waste and abuse in our federal health care programs,” said CMS Administrator Chiquita Brooks-LaSure. “The administrative actions CMS has taken protect the Medicare Trust Funds while also safeguarding people enrolled in Medicare.”

Read the DOJ press release.

 
Image Depicting Healthcare Fraud Waste and Abuse in the Context of COVID-19
Released in January 2022: Fraud, Waste, and Abuse in the Context of COVID-19 White Paper

The Healthcare Fraud Prevention Partnership (HFPP) released its newest White Paper, “Fraud, Waste, and Abuse in the Context of COVID-19 (PDF)” in collaboration with Stanford University School of Medicine.

This new HFPP white paper provides a background on COVID-19 and its impact on healthcare delivery. The paper then highlights trending fraud schemes and offers strategies for healthcare payers to consider and apply.

Broadly, this white paper outlines important steps that federal and state agencies, private payers, and law enforcement have taken in identifying and responding to fraud, waste, and abuse related to the delivery of care for COVID-19. These actions and lessons learned may allow these parties to anticipate vulnerabilities moving forward, providing a foundation for navigating a changed healthcare landscape and future healthcare challenges.

For additional information, please see:

 
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False Claims Act Cases Against P-Stim Providers and Suppliers

On October 14, 2021, Acting United States Attorney Jennifer Arbittier Williams of the Eastern District of Pennsylvania announced three settlements and the filing of a complaint under the False Claims Act. These are the latest law enforcement actions in the national investigation into the scheme of improper billing involving P-Stim electro-acupuncture devices. Federal healthcare programs do not reimburse for P-Stim devices, whether they are characterized as an electro-acupuncture device or as an implantable neuro-stimulator.

The four enforcement actions announced by U.S. Attorney Williams allege that certain parties sold P-Stim devices and/or promoted them as billable to Medicare and other federal healthcare programs, which then caused providers to submit fraudulent claims. The United States alleges that these promoters profited by conspiring together to make false representations to providers that P-Stim was reimbursable under billing codes that paid thousands of dollars per procedure. Those codes were meant for legitimate, surgically implanted neuro-stimulators to manage chronic pain. However, P-Stim devices can be applied in a few minutes in an office setting without anesthesia by someone with minimal training. The promoters allegedly had knowledge that the P-Stim devices were not reimbursable by federal healthcare programs but pushed the non-surgical devices anyway.

“CMS is dedicated to removing fraudulent actors and protecting the people who rely on our programs,” said CMS Administrator Chiquita Brooks-LaSure. “We thank our partners at the Department of Justice and Department of Health and Human Services Office of Inspector General for collaborating with us to identify, investigate, and eliminate waste, fraud, and abuse in our federal health care programs.”

CMS aggressively investigates providers and suppliers to ensure appropriate payments are billed to federal healthcare programs, including through the use of data-analytic investigative tools. The U.S. Attorney’s Office for the Eastern District of Pennsylvania and other law enforcement partners have pursued and settled various False Claims Act cases against P-Stim providers and suppliers, recovering millions. Including the three settlements, the national P-Stim initiative has so far produced over 15 False Claims Act settlements across the country worth approximately $15 million. Additionally, outside of DOJ litigation, there are administrative enforcement actions by other federal agencies as well. In particular, CMS, through its Program Integrity Contractors, is auditing and recovering improperly paid P-Stim claims. HHS-OIG is also pursuing civil money penalties and exclusion remedies.View Previous Spotlights

 

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Page Last Modified:
02/01/2023 09:49 AM