CMS announces new weapons to fight fraud

The Centers for Medicare and Medicaid Services (CMS) has announced new rules designed to address fraud in federal health insurance programs. Beginning in November, providers and suppliers will have to disclose their current or past affiliations with other health care providers whose payments are, or have been, suspended or excluded from federal health care programs. They will also have to disclose if they have uncollected debt related to such programs. The idea is to prevent fraud before it happens by keeping fraudsters out of the program.

The new rule also strengthens CMS’ ability to revoke enrollment for up to 10 years, compared to the current three years. The new program integrity requirements reflect the government’s increased efforts to crack down on the fraud that costs the government billions of dollars each year.

Even innocent mistakes can blossom into fraud cases if they are ignored.

Last year, the government recovered $2.3 billion in health care fraud judgments and settlements in addition to administrative fines. In 2018, the Department of Justice opened 1,139 criminal health care fraud investigations and 918 new civil health care fraud investigations.

At least two recent examples involved the practice of allergy. In one case, a practice was found to have improperly billed for sublingual immunotherapy - which is not covered by Medicare and other payers; they also overstated the units of allergen immunotherapy provided to patients.  This case resulted in a settlement of over $740,000.  Another case involved submission of claims for intracutaneous tests that were never provided and resulted in a settlement of $751,000.

Even innocent mistakes can blossom into fraud cases if they are ignored. The law requires the return of any Medicare overpayments to the government within 60 days of the provider becoming aware of the overpayments. Failure to do so can result in civil and criminal charges.  Therefore, allergists, together with their staff, need to pay attention to their billing practices. If Medicare overpayments are identified, they should be returned immediately.  You may also wish to consult health care legal counsel, especially if large amounts are involved.