House Lawmakers Criticize CMS’ Medicare Fraud Efforts
At a House subcommittee hearing on Tuesday, Republicans and Democrats criticized the Obama administration's efforts to address Medicare payment fraud, arguing that compliant providers could be harmed by the program's excessive oversight and a costly, time-consuming appeals process, Modern Healthcare reports.
Since the enactment of the Affordable Care Act, the Obama administration has strengthened its efforts to combat Medicare fraud and waste, according to Modern Healthcare. For example, the Health Care Fraud and Abuse Control Program has recouped $19.2 billion in improper payments to providers over the past five years, more than twice the amount collected during the previous five-year period.
However, the Office of Medicare Hearings and Appeals in 2013 introduced a temporary moratorium on assigning new appeals of Medicare payment decisions to administrative law judges, citing a backlog of pending cases. This year, OMHA estimates a backlog of more than one million appeals, Modern Healthcare reports.
At the hearing, lawmakers on the House Oversight and Government Reform Subcommittee on Energy Policy, Health Care and Entitlements heard testimony from administration and government oversight agency officials tasked with fraud oversight.
Panel members from both sides of the aisle largely agreed that while providers found to be in violation of Medicare fraud rules must be penalized, the process for appealing flagged payment decisions is highly flawed and offers limited protections for those who have been wrongly denied payments for care they delivered.
Rep. Michelle Lujan Grisham (D-N.M.) said, "The due process system is clearly broken." She added, "Large hospitals and large hospital groups can afford to wait a decade potentially. Small hospitals cannot."
Similarly, Subcommittee Chair James Lankford (R-Okla.) said, "We want Medicare providers to be there; we want our seniors to have access," but "[w]e're losing the good guys in this, and that's going to hurt us long term."
In response, CMS Center for Program Integrity Director Shantanu Agrawal acknowledged that CMS is trying to "strike an important balance" between "limiting the administrative burden on legitimate provider[s] and suppliers to preserve beneficiary access to necessary health care services" and "fulfilling [the agency's] obligation to ensure taxpayer dollars are not lost to waste, abuse and fraud."
Similarly, Brian Ritchie, acting deputy inspector general for evaluation and inspections at the HHS Office of Inspector General, said that "all key players -- including CMS, OMHA and Congress" -- need to work together to "address this issue" (Demko, Modern Healthcare, 5/20).
GAO: CMS Must Finalize, Offer Additional Rules
In conjunction with the hearing, the Government Accountability Office issued a report commending the federal government for its anti-fraud and anti-waste efforts, but it urged CMS to clarify and implement additional rules to stem provider confusion and help ensure that improper payments are not issued in the first place, the Washington Times reports.
Ritchie in his testimony said, "All fraud is certainly improper payments, but all improper payments are not fraud," adding that "most of these providers are not committing fraud, they just don't understand a complex system" (Howell, Washington Times, 5/20).
Ritchie and Kathleen King -- GAO's director of health care, who also testified at the hearing -- outlined several steps that CMS could take to better address and limit fraud.
Specifically, they recommended that CMS adopt stricter enrollment requirements and prepayments to ensure that the government is reimbursed for incorrect payments. For example, they cited:
- A proposed rule that would require certain at-risk providers and suppliers to hold surety bonds to repay CMS in instances of overbilling;
- A rule, not yet finalized, that would require providers and medical equipment suppliers to disclose past billing issues before enrolling in Medicare; and
- A rule, also not yet finalized, that would require Medicare Part D prescribers to be enrolled in the Medicare fee-for-service program, which could bolster CMS' monitoring of the program (Al-Faruque, The Hill, 5/20).