CMS Ups Its Game in Going After Medicare Fraud

Recent headlines have put Medicare fraud—and the search for those committing it—in the spotlight. However, urgent care clinicians who toe the line in treating Medicare patients are less likely to face unwarranted audits in the future—while fraudsters are putting themselves more at risk than ever—under a new system revealed by the Centers for Medicare and Medicaid Services (CMS). The agency is essentially narrowing the scope of practices it will investigate for fraud, hoping it will net a higher percentage of success than its current shotgun approach. The new process, called Targeted Probe and Educate, will target Medicare providers and suppliers with a history of higher-than-average error rates, or billing practices that are out of step with the majority of their peers. Up until now, Medicare administrative contractors (MACs) have randomly selected Medicare claims to evaluate for fraud. Successes have come out of the current process, but at the cost of a tremendous backlog of appeals; too many innocent providers are being forced to refute the charges, while the MACs are simply unable to focus on enough of the most likely culprits. CMS says the MACs will now “select claims for items/services that pose the greatest financial risk to the Medicare trust fund and/or those that have a high national error rate.” CMS will also start working with providers to address claims errors