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Medicare has been considered a “High Risk program” by the Government Accountability Office since 1990 due to its size, complexity and susceptibility to improper payments. In 2018, improper payments accounted for 5% of the total $616.8 million of Medicare’s net costs.

Recent variations to Medicare, such as different provider types and new value-based payment programs, have made program integrity risks even more difficult to recognize.

In addition, with an aging baby boomer population, the importance of a secure Medicare program is greater than ever. There are nearly 61 million Medicare beneficiaries, and CMS is adding 10,000 new enrollees every day.

It is under these transformations that CMS is re-framing its approach to Medicare program integrity, according to a recent blog post by the Centers for Medicare and Medicaid Services’s (CMS) Administrator Seema Verma.

CMS’s modernized five-pillar strategy is as follows:

  • Stop bad actors – CMS will continue to work with the Office of the Inspector General, the Department of Justice and the Unified Program Integrity Contractors to identify potential health care fraud cases, direct them to law enforcement and take appropriate administrative action. One recent collaboration resulted in $3.3 billion dollars in saving.
  • Prevent fraud – CMS is improving infrastructure to prevent fraud, waste and abuse. After identifying bad actors, CMS now makes system changes to avoid future similar activities. For example, to mitigate risks to send new Medicare cards to beneficiaries, CMS implemented an enhanced address validation process to verify beneficiaries’ identities and addresses against multiple information sources.
  • Mitigate emerging programmatic risks – In order to be vigilant in monitoring new and emerging areas of risk, CMS will continue to implement prior authorization to a bevy of high-risk medical items, such as prosthetics and orthotics, which have been subject to telemarketing fraud schemes.
  • Reduce provider burden – Alongside CMS’s Targeted Probe and Educate program and other efforts, CMS will continue to educate providers on CMS program rules and regulations to ensure efforts to strengthen program integrity does not create unnecessary time and cost burden on providers. One-on-one education has recovered more than $10 billion since 2009. In addition, CMS will remedy onerous process to help rather than punish providers who make good faith claim errors and will streamline recovery audit processes.
  • Leverage new technology – CMS is seeking to incorporate innovative technology in its program integrity efforts to review claims and other medical records more efficiently. It is particularly interested in artificial intelligence and machine learning, as the agency believes automation could reduce burdens for providers and costs for taxpayers.

CMS released a new request-for-information to obtain input on how the agency can better use emerging technologies to ensure proper claims payment, reduce provider burden and conduct program integrities in a more efficient manner.



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