Monday, October 27, 2008

Thirteen Recommendations for Eliminating Medicare Fraud

Tough new steps must be taken to prevent fraud and abuse in Medicare. The American Association for Homecare announced 13 specific recommendations that could eliminate most of the Medicare fraud attributed to the home medical equipment (HME) sector. The Association has been working with Congress and regulators over the past year to adopt tougher, more effective measures to combat Medicare fraud.

The specific recommendations made by the American Association for Homecare include:

Mandate Site Inspections for All New Home Medical Equipment Providers
A July 2008 GAO report underscored the need for CMS to ensure that its contractors are conducting effective site inspections for all new applicants for a Medicare supplier number.

Require Site Inspections for All HME Provider Renewals
All renewal applications should require an in-person visit by the National Supplier Clearinghouse (NSC), the contractor that CMS uses to ensure integrity in the Medicare program.

Improve Validation of New Homecare Providers
Additional validation of new providers should be included in a comprehensive and effective application process for obtaining a Medicare supplier number.

Require Two Additional Random, Unannounced Site Visits for All New Providers
Two unannounced site visits should be conducted by NSC during the first year of operation for new HME providers.

Require a Six-Month Trial Period for New Providers
The NSC should issue a provisional, non-permanent supplier number to new suppliers for a six-month trial period. After six months of demonstrated compliance, the provider would receive a “regular” supplier number.

Establish an Anti-Fraud Office at Medicare
CMS should establish an office with the sole mandate of coordinating detection and deterrence of fraud and improper payments across the Medicare and Medicaid programs.

Ensure Proper Federal Funding for Fraud Prevention
Increase federal funding to ensure that NSC completes site inspection and other anti-fraud measures.

Require Post-Payment Audit Reviews for All New Providers
Medicare’s program safeguard contractors should conduct post-payment sample reviews for six months worth of claims submitted to Medicare by new providers.

Conduct Real-Time Claims Analysis and a Refocus on Audit Resources
Medicare must analyze billings of new and existing providers in real time to identify aberrant billing patterns more quickly.

Ensure All Providers Are Qualified to Offer the Services They Bill
A cross-check system within Medicare databases should ensure that homecare providers are qualified and accredited for the specific equipment and services for which they are billing.

Establish Due Process Procedures for Suppliers
CMS should develop written due process procedures for the Medicare supplier number process, including issuance, denial and revocation of the Medicare supplier number. The procedures must include, for example, an administrative appeals process and timelines.

Increase Penalties and Fines for Fraud
Congress should establish more severe penalties for instances of buying or stealing beneficiaries’ Medicare numbers or physicians’ provider numbers that may be used to defraud the government.

Establish More Rigorous Quality Standards
Ensure that all accrediting bodies are applying the same set of rigorous standards and degree of inspection to their clients.

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