CMS Announces Plans to Address Medicare Program Integrity

October 24, 2019
Policy Snapshot

Seema Verma, administrator for the Centers for Medicare & Medicaid Services (CMS), has announced plans to modernize Medicare’s integrity methods to protect from fraud, waste, and abuse. CMS is developing a five-pillar program integrity strategy:

  • Stop Bad Actors: CMS will increase their work with the Office of the Inspector General (OIG), Department of Justice (DOJ), and the Unified Program Integrity Contractors (UPICs) to deliberate on potential health care fraud cases, quickly direct them to law enforcement, and take appropriate administrative action such as payment suspensions and revocations.
  • Prevent Fraud: Improving infrastructure that prevents fraud, waste, and abuse on the front end. After CMS identifies bad actors and their schemes, CMS will make system changes to avoid similar fraudulent activities in the future. CMS’ oversight, audit, and investigative activities allow them to analyze data to identify potential problem areas.
  • Mitigate Emerging Programmatic Risks: Implementing prior authorization for newly identified items as well as additional items to help ensure that services billed are medically necessary.
  • Reduce Provider Burden: CMS will increase efforts to educate providers about CMS program rules and regulations and remedy onerous processes to assist rather than punish providers who make good faith claim errors. That’s the purpose of CMS’ Targeted Probe and Educate (TPE) program and their efforts to streamline the recovery audit processes.
  • Leverage New Technology: CMS is seeking new, innovative strategies and technologies, perhaps involving artificial intelligence and/or machine learning, which are more cost effective and less burdensome to both providers, suppliers, and the Medicare program. This new technology could allow the Medicare program to review compliance on more claims with less burden on providers. Advanced analytics and artificial intelligence (AI) can perform rapid analysis and comparison of large-scale claims data and medical records that could allow for more expeditious, seamless, and accurate medical review, and ultimately, improved payment accuracy. CMS has issued an RFI on Using Advanced Technology in Program Integrity.

CMS also has issued an RFI on the Future of the Program Integrity.

Click here to read more details about the program integrity plan.