CMS rule targets Medicare fraud as GAO says more could be done

Even as the Centers for Medicare & Medicaid Services (CMS) announced a final rule Tuesday aimed at preventing Medicare fraud and saving taxpayers nearly $1.6 billion over 10 years, the GAO came out with a report urging CMS to do more.

The GAO found persistent weaknesses in Medicare’s enrollment standards and procedures that increased the risk of enrolling entities intent on defrauding the program. It called for pre- and post-payment claims review and for  mechanisms in place to resolve vulnerabilities

[See also: Sebelius, Holder put spotlight on fight against Medicare fraud]

"The Medicare program is difficult to measure in a reliable way," GAO stated in its report, "but it is clear that fraud contributes to Medicare’s fiscal problems. Reducing fraud could help rein in the escalating costs of the program."

The new CMS rule is inttended - in part - to address some vulnerabilities. CMS officials say it ensures that only qualified, identifiable providers and suppliers can order or certify certain medical services, equipment and supplies for people with Medicare. It also helps ensure beneficiaries receive quality care because CMS will verify the credentials of a provider who is ordering or certifying equipment and supplies.

CMS has employed information technology and automated many of the tools for detecting and preventing fraud, aiding in implementing rules aimed at combating fraud and maintaining data security.

[See also: CMS awards $78M cybersecurity contract]

“Thanks to the Affordable Care Act, we are expanding our work to combat fraud,” said deputy administrator for program integrity Peter Budetti. “This rule will save money for taxpayers and ensure people with Medicare get high-quality care.”

In addition, the final rule continues to require that all providers and suppliers who qualify for a unique identification number – the National Provider Identifier (NPI) – include their NPI on applications to enroll in Medicare and Medicaid and on all reimbursement claims submitted. This gives CMS and states the ability to tie specific claims to the ordering or certifying physician or eligible professional and to check for suspicious ordering activity.

This rule builds on the work CMS is also doing in Medicare Part D by requiring all prescriptions include an NPI for prescribing physicians. In conjunction with Part D, these efforts will help better safeguard the Medicare Trust Funds by giving CMS the ability to know which providers are ordering, certifying and prescribing items and services to Medicare beneficiaries, CMS officials say.

[See also: CMS targets fraud with new analytics]