Medicare Compliance & Reimbursement

New ‘five-pillar’ program aims to cut the rates upfront.

Due in part to the skyrocketing costs of healthcare, Medicare wants to reduce improper payments from the get-go.

Details: Back in September, the Centers for Medicare & Medicaid Services (CMS) released a final rule in the Federal Register titled “Program Integrity Enhancements to the Provider Enrollment Process.” The rule outlined the agency’s initiative to utilize the Medicare enrollment system to stop fraudsters before they joined the program (see Medicare Compliance & Reimbursement, Vol. 45, No. 18).

Now: CMS expanded on this integrity plan with its “five-pillars program” to combat improper payments and cut Medicare fraud before it starts.

“Our progress on improper payments is historic, but there’s more work to be done,” says Seema Verma, CMS administrator, in a release. “CMS has taken a multifaceted approach that includes provider enrollment and screening standards to keep bad actors out of the program, enforcement against bad actors, provider education on our rules and requirements, and advanced data analytics to stop improper payments before they happen.”

Take a look at the five-pillars program’s focus areas:

• Bad actors: CMS aims to use a variety of resources to “stop bad actors” from taking advantage of federal healthcare programs.
• Prevention: Using screening and background information, the feds hope to nip issues in the bud and prevent fraud, abuse, and waste on the front end.
• Risk reduction: Value-based care remains one of Medicare’s primary focuses, and the agency plans to protect its cost-saving, pro-patient initiatives by exploring “ways to identify and reduce program integrity risks” by utilizing experts in the field, the release suggests.
• Administration cutbacks: CMS made administrative burden rollbacks a priority a while ago, and the pillars build on that by promoting simplified coverage and payment rules, paperwork reductions, and duplication cuts.
• Health IT: The agency wants to utilize technologies like artificial intelligence and machine learning to streamline the payment process and reduce claims burdens for providers.

Verma adds, “These initiatives strike an important balance between preventing improper payments and reducing the administrative burden on legitimate providers and suppliers.”