July 1, 2011
Up until now, Medicare fraud was usually caught – if it’s caught at all – when a Medicare strike force actively investigates anomalous claims. It’s been said that Medicare fraud is a very strange phenomenon, in which the police are the ones to tell the victims that a crime has happened, not the other way around.
But that may change. The White House, as part of its Campaign to Cut Waste, has contracted with Northrop Grumman to use complex algorithms and predictive model technology to scan through Medicare files and flag potential fraud and abuse. The system is scheduled to go into effect in July 2011.
The Centers for Medicare and Medicaid Services (CMS), in a Press Release said, “Northrop Grumman will deploy algorithms and an analytical process that looks at CMS claims – by beneficiary, provider, service origin or other patterns – to identify potential problems and assign an ‘alert’ and assign ‘risk scores’ for those claims.”
What does this mean for laboratories and physicians? It means you’d better get your compliance and Medicare house in order. Before, due to the sheer volume of Medicare claims, labs and doctors might be able to – unintentionally or otherwise – get away with inaccurate or shoddy Medicare claims, but those days may be over.
The Affordable Care Act (ACA, health care reform), takes a new tough stance on health care fraud, resulting in stiffer penalties. It also makes it easier for the government to levy finds and recapture money acquired through fraud. It also makes it easier for the Department of Justice (DOJ) to investigate potential fraud.
And it doesn’t stop there. Beginning March 25, 2011, some new providers and suppliers started being screened before being enrolled in Medicare, Medicaid or Children’s Health Insurance Program (CHIP). This was to potentially rule weed out bad risks. CMS, with the Office of Inspector General (OIG), can also suspend Medicare payments to providers or suppliers if there is “a credible allegation of fraud.”
In short, health care reform brought the hammer down, moving away from what has been called the “pay and chase” method of tracking down fraud after the fact. Now, by using technology, empowering law enforcement, and adding muscle and speed on the punitive end, CMS and the federal government is intent on catching fraud while it’s happening – or even before.
Are you ready?
Lessons Learned
- CMS has contracted with Northrop Grumman to use cutting-edge computing technology to identify potential Medicare fraud.
- Health care reform has led to stiffer penalties and a more proactive and ambitious approach to preventing, identifying and punishing Medicare fraud.
- Laboratories and physicians need to get on the ball and make sure their compliance programs and Medicare and Medicaid billing functions are in good working order.
LabPath professionals have a wealth of experience in assisting laboratories in building strong billing financial management systems, implementing effective compliance programs and conducting audit assessments to identify and eliminate risks.
For questions concerning this LabPath News Alert and/or the services available to assist laboratories in implementing and maintaining an effective compliance program, please email us at vasb@ynocngupbafhygvat.pbz or call at 727-244-1150.