Waste and Fraud

CMS is planning an overhaul of Medicaid eligibility regulations after the national improper pay estimates for the program hit 14.9% for fiscal 2019, and the agency is developing a proposed rule focused on insufficient recordkeeping, eligibility verification, redeterminations and compliance with eligibility requirements when beneficiaries’ circumstances change.

CMS proposed a wide-ranging new rule Tuesday (Nov. 12) that the agency says will crack down on states manipulating Medicaid supplemental payments in order to obtain extra federal matching funds.

CMS on Thursday (Sept. 5) finalized a sweeping program-integrity rule -- first proposed under the Obama administration -- that gives the agency greater latitude to block health care providers from participating in Medicare, Medicaid or the Children’s Health Insurance Program if they are affiliated with entities who are deemed to pose a heightened risk of fraud, waste or abuse.

HHS recently withdrew rules proposed decades ago that would have codified the HHS Office of Inspector General’s ability to penalize hospitals that offer doctors incentives to reduce care for Medicare and Medicaid beneficiaries and would have expanded an existing safe harbor to include waivers of beneficiary cost sharing for those with certain Medigap plans.

The House late on Tuesday (June 18) passed legislation that would fund the Money Follows the Person demonstration through 2024, preserve asset protections for the spouses of Medicaid beneficiaries who receive long term care benefits and extend the Community Mental Health Services Demonstration.

The Trump administration late Wednesday (May 1) told a federal appeals court it agrees with a district judge’s ruling that the entire health care law is invalid, yet also asked the court to retain certain ACA provisions the administration claims would not harm the plaintiffs, including updates to Medicare fraud laws – a move that left key legal experts scratching their heads.

The Office of Inspector General (OIG) is asking for $10 million in additional funding in fiscal 2020 to target fraud, waste and abuse in home and community-based settings, with a focus on four geographic hotspots that OIG associates with “suspicious behavior” -- Florida, Texas, and select areas in Southern California and the Midwest.

Senate Finance Committee Chair Chuck Grassley (R-IA) and health subcommittee Chair Pat Toomey (R-PA) on Friday (March 8) lambasted CMA for failing to recoup improper Medicaid eligibility-related payments in excess of 3 percent made by states since 1992 and asked the agency to respond by March 15 on how they plan to fix the situation and whether they need Congress’ help to do so.

Senate Finance Committee Chair Chuck Grassley (R-IA) on Wednesday (Jan. 9) said he expects to spend time looking at Medicare and Medicaid waste, fraud and abuse now that he has resumed the chairmanship, along with health care anti-trust issues.