Critical Steps to Curtail Medicaid Fraud

19 May Critical Steps to Curtail Medicaid Fraud

The watchdog for the U.S. Congress, the Government Accountability Office (GAO), designates Medicare and Medicaid as a high-risk plans, because it’s a complicated program, which is in danger from fraudulent activity. Fraud, in this case, involves deception resulting in a profitable gain at the expense of the U.S. Federal Government. Curb fraud and Medicare’s swelling price tag might be reined in. Here are the steps taken and future actions required to restrain Medicare fraud, according to the GAO.

Strengthen Provider Enrollment Requirements

The GAO has found continual weak areas in the methodology used by the Centers for Medicare & Medicaid Services (CMS), the federal agency that handles Medicare and Medicaid, to enroll Medicare providers. If enrollment procedures were strengthened, potential fraud might be deterred.

For instance, in early 2011, CMS established a limited, moderate and high level of risk for providers and created varied screening measures for each category. But, the GAO found that CMS had not performed the following actions, as specified by the Patient Protection and Affordable Care Act (PPACA):

  • Create core elements for compliance programs for providers.
  • Distribute a regulation requiring extra provider information.
  • Set up background checks based on fingerprints.
  • Specify which providers will be made to post surety bonds, which in turn, will guarantee the recovery of fraudulent claims.

The Review Claims Before and After Payment

Previously, the GAO established that investigating claims prior to payment would decrease instances of fraud. The GAO also said that enhancing methods of reviewing claims after they were paid might slow future fraudulent claims.

Procedures exist with CMS in processing Medicare & Medicaid claims, which determine whether to review, deny or pay each claim based upon information about providers. Such a screening requires that provider information be as current as possible, a process that the GAO previously said CMS needs to intensify.

The GAO is checking how CMS alters information that is used to determine payment and coverage policies, along with the CMS’s Fraud Prevention System, a methodology of utilizing analytics prior to making payments. If CMS implemented prior GAO recommendations on developing plans and timelines while winnowing out examples of fraud, it could do a better job at winning the battle, especially if it combined data from Medicare with additional data into one larger web portal database.

Vigorous Procedure Needed to Tackle Deficiencies

The need is urgent for establishing procedures that help identify weaknesses in identifying fraudulent claims. System- or service-specific deficiencies can result in payment errors, such as multiple payments to providers for the same service, due to code errors. This is an area already tagged by the GAO as a CMS weakness. Today, the GAO is investigating changes in CMS processes in order to determine whether the deficiency is now strengthened.