Corporate Compliance

HHS outlines new Affordable Care Act rules to fight healthcare fraud

Compliance Monitor, February 2, 2011

HHS announced new rules authorized under the Affordable Care Act which will help stop healthcare fraud.  According to an HHS press release, the new authorities allow the government to develop sophisticated, new systems of monitoring and oversight to crack down on fraudulent activity. 

Specifically, the final rule:

  • Creates a rigorous screening process for providers and suppliers enrolling Medicare, Medicaid, and CHIP to keep fraudulent providers out of those programs.  Types of providers and suppliers that have been identified in the past as posing a higher risk of fraud (for example, durable medical equipment suppliers) will be subject to a more thorough screening process. 
  • Requires new enrollment process for Medicaid and CHIP providers.  Under the Affordable Care Act, states will have to screen providers who order and refer to Medicaid beneficiaries to determine whether they have a history of defrauding the government.  Providers that have been kicked out of Medicare or another state’s Medicaid or CHIP will be barred from all Medicaid and CHIP programs.
  • Temporarily stops enrollment of new providers and suppliers.  Medicare and state agencies will be on the lookout for trends that may indicate healthcare fraud – including using advanced predictive modeling software, such as that used to detect credit-card fraud.  If a trend is identified in a category of providers or geographic area, the program can temporarily stop enrollment as long as that will not impact access to care for patients.
  • Temporarily stops payments to providers and suppliers in cases of suspected fraud.  Under the new rules, if there has been a credible fraud allegation, payments can be suspended while an action or investigation is underway.

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