Waste and Fraud

The White House Office of Budget and Management’s review of CMS’ tweaked home health pre-claims review demonstration, now called the Review Choice Demonstration for Home Health Services, has seemingly stalled since CMS submitted it to OMB for review, leaving Illinois providers preparing for a demonstration with an uncertain start date.

The White House Office of Management and Budget on Monday (Dec. 3) began reviewing a final rule aimed at improving the Medicare provider enrollment process in order to beef up program integrity.

The federal DC district court again ordered HHS to clear the backlog of Medicare appeals, saying that since the department told the court it could clear the backlog in fiscal 2022, the agency should do so by the end of that year and provide the court with updates on its progress.

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.