Waste and Fraud

A federal judge on Friday (Sept. 7) struck down a 2014 CMS rule that imposed a strict definition of Medicare Advantage overpayments and an exacting liability standard for when MA plans were required to report such overpayments and return them to CMS.

HHS projects that recent settlements and increased funding from Congress should allow the department to eliminate the Medicare appeals backlog in fiscal 2022 -- assuming the higher funding level for the Office of Medicare Hearings and Appeals continues -- so the district court shouldn't require anything but status reports from the department.

CMS will tweak a demonstration in order to continue allowing providers affected by state-wide moratoria on home health agencies and non-emergency ambulances to participate in Medicare, Medicaid and CHIP if there are proven access to care concerns, and the agency also will allow those that had a pending application denied when state-wide moratoria kicked in to participate in the programs through the demo.

CMS on Monday (July 30) announced it would continue for another six months moratoria on Medicare, Medicaid and CHIP participation for new non-emergency ground ambulance suppliers in New Jersey and Pennsylvania and home health agencies in Florida, Illinois, Michigan and Texas.

CMS Administrator Seema Verma said the agency has a long way to go to prevent Medicare waste, fraud and abuse, and pointed to the small percentage of claims that Medicare reviews, though Center for Program Integrity Director Alec Alexander recently touted Medicare's falling improper pay rate before a House Ways & Means panel.

The Government Accountability Office says in a Wednesday (June 6) report that CMS isn't looking closely enough at Medicaid managed care plans, including whether those plans overpay providers or have so-called unallowable costs, and the office recommended that CMS take steps to make sure it is accurately looking at Medicaid plans' improper pay rate.

Republican House Energy & Commerce leaders are asking HHS Secretary Alex Azar how he plans to fix the Medicare appeals backlog, the Medicaid improper pay rate and Medicaid financial reporting problems.

The drop in CMS' improper pay rate for fee-for-service Medicare was driven by a reduction in improper pay to home health agencies and inpatient rehabilitation facilities -- though CMS says home health companies and IRFs, along with nursing homes, were the major contributors to the 9.5 percent improper pay rate in fiscal 2017, and the HHS Office of Inspector General said program integrity is still a top management challenge for the agency.

Senate Finance ranking Democrat Ron Wyden said Friday (June 30) he is investigating whether CMS Administrator Seema Verma violated her ethics agreement by speaking to a Medicaid adviser to Arkansas’ Department of Human Services, a state covered by Verma’s ethics agreement due to her previous consulting work.