New Fraud Detection Probes by Medicare

The Patient Protection and Affordable Care Act is changing the way Medicare and Medicaid fraud are handled. Provisions in the law give the Centers for Medicare and Medicaid Services (CMS) the ability to stop fraud before it happens, as opposed to the old “pay-and-chase” system, which entailed seeking reimbursement of fraudulent claims after they were paid.

The new initiative, called the National Fraud Prevention Program (NFPP), aims to cut the rate of improper payment claims in half. The NFPP focuses on provider enrollment and claims payment. By including these two steps in one program, CMS will be able to better screen providers and pay only valid claims from the beginning. To reach their goal, the NFPP instituted the Automated Provider Screening (APS) system, as well as a new national site visit program employing National Site Visit Contractors.

The APS involves automatic data checks to identify fraud, waste, and abuse. It is designed to verify information on the enrollment application from both private and public databases. This process will result in less manual review of applications, and will allow for the monitoring of accuracy of enrollee data. It will determine the level of risk each enrollee poses to the Medicare program, and enable the continuous update of relevant enrollment information. The program was beta-tested last year using Medicare fee-for-service claims; however, reimbursement was not withheld until now.

With the official launch of the NFPP, CMS is monitoring 4.5 million claims using “sophisticated algorithms and models to identify suspicious behavior.” If fraudulent patterns are detected, the findings are turned over to Zone Program Integrity Contractors, and, if necessary, to law enforcement.

The new national site visit verification process is used to screen providers that Medicare considers questionable before fully enrolling them in the Medicare program. The National Site Visit Contractors will meet with providers and suppliers during the enrollment period and verify all of the information received by CMS. During site visits, the contractor will collect specific information based on a predefined checklist from CMS and give a recommendation to CMS to proceed or deny enrollment of a provider or supplier.

Proper record keeping and documentation are your key defenses against fraud, waste, and abuse. By maintaining accurate and credible medical records, you will protect your practice and your patients. Accurate and timely documentation of patient visits will always put you on the right path for coding the proper level and avoid any misconception of fraud and abuse. You have a duty to ensure that all records accurately reflect the treatment or services rendered. There is nothing more devastating to a physician’s defense of fraud and abuse than an inaccurate, illegible, or skimpy record. Remember, if something is not documented, it is not billable.

The ACR is dedicated to providing all the necessary tools for you and your staff regarding documentation and coding. If you need any assistance on coding and reimbursement, contact ACR coding specialist Melesia Tillman, CPC-I, CRHC, CHA, at (404) 633-3777, ext. 820, or [email protected]. Join the ACR coding listserv at www.rheumatology.org/membership and post your questions online.