Share of Cost, CMS Offers New Safeguards and Incentives in Preventing Medicare Fraud

Friday, Jan. 31st 2014 9:15 AM

Last week the Centers for Medicare and Medicaid Services (CMS) announced increasing its incentives/rewards programs for individuals who provide leads on fraudsters and/or Medicare fraud schemes that result in the recovery of funds. In the past CMS provided a reward of 10% of the final amount collected with a cap at the first $10,000 recovered (or a $1,000 reward). Now CMS is providing a reward of 15% of the final amount collected for the first $66 million in recovered funds. This means a person who provides a successful lead could receive an award for up to $9.9 million.

CMS has also added some new provider enrollment provisions aimed at further increasing the integrity of the Medicare program and reducing fraud. Below is a summary of the new provisions as stated in their fact sheet:

  • 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.


Posted on Friday, Jan. 31st 2014 9:15 AM | by Share of Cost | in Social Security | Comments Off on Share of Cost, CMS Offers New Safeguards and Incentives in Preventing Medicare Fraud