New Medicare anti-fraud rule proposed

Sept. 20, 2010 at 7:12 PM
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WASHINGTON, Sept. 20 (UPI) -- U.S. officials proposed new anti-fraud measures they say would require Medicare providers considered high risks for fraud to undergo stricter scrutiny.

Among other things, the rule proposed Monday by Centers for Medicare and Medicaid Services would require Medicare providers with a "high risk" of defrauding the government to be subject to fingerprinting and possible background checks, MedPageToday.com reported.

The proposed rule, part of the Affordable Care Act signed in March by President Barack Obama, "strikes a balance that will permit CMS to continue to assure that eligible beneficiaries receive appropriate services from qualified providers whose claims are paid on a timely basis while implementing enhanced measures to prevent outright fraud," CMS said.

The rule would "assure that only legitimate providers and suppliers are enrolled in Medicare, Medicaid, and (the Children's Health Insurance Program), and that only legitimate claims will be paid," the agency said.

The impetus behind the rule is to help CMS transition to a fraud prevention strategy from its "pay and chase" approach, under which providers are paid and then Medicare determines which payments were fraudulent and then "chases" the suspect providers to get the money back.

MedPageToday.com said the proposed rule would classify Medicare providers under one of three categories:

-- Limited-risk providers, who would have to meet enrollment requirements, license and database verifications.

-- Moderate-risk providers, who would meet the low-risk provider requirements and be subject to unscheduled site visits.

-- High-risk providers, who would have to meet the initial requirements, and undergo unscheduled site visits, criminal background checks and fingerprinting.

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