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«SHANTANU AGRAWAL, M.D. DEPUTY ADMINISTRATOR AND DIRECTOR, CENTER FOR PROGRAM INTEGRITY CENTERS FOR MEDICARE & MEDICAID SERVICES ON “MEDICARE AND ...»

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Additionally, CMS uses site visits to verify that a provider's or supplier's practice location meets Medicare requirements, which helps prevent questionable providers and suppliers from enrolling or maintaining enrollment in the Medicare program. As of May 2016, CMS has performed over 290,000 site visits on Medicare providers and suppliers since 2011. CMS has the authority, when deemed necessary, to perform onsite review of a provider or supplier to verify that the enrollment information submitted to CMS or its agents is accurate and to determine compliance with Medicare enrollment requirements. 11 Under this authority, CMS has increased site visits, 10 Note: Providers and suppliers that may be exempted from the deactivation for non-billing include: those enrolled solely to order, refer, prescribe; or certain specialty types (e.g., pediatricians, dentists and mass immunizers (roster billers)).

11 42 C.F.R. 424.517 6 initially focusing on those providers and suppliers receiving high reimbursements by Medicare that are located in high risk geographic areas.

CMS has also made additional improvements to the National Site Visit Contractor (NSVC) training processes since the HHS-OIG completed a review of provider enrollment activities. 12 All NSVC inspectors are required to receive CMS approved training and testing and undergo annual retraining. In addition, reminders and updates to procedures are provided to the inspectors throughout the year through bulletins and newsletters. All site inspections are reviewed by an NSVC official before being submitted to CMS. In addition, certain site inspections undergo a second level of quality assurance by an independent official that includes interviews with the provider and the inspector. CMS may take corrective action based on the results of this process.

CMS Oversight of State Medicaid Provider Enrollment Because Medicaid is jointly funded by states and the Federal Government and is administered by states within Federal guidelines, both the Federal Government and states have key roles as stewards of the program, and CMS and states work together closely to carry out these responsibilities.

States bear the primary responsibility for provider screening, credentialing, and enrollment for Medicaid. CMS has taken several steps to help states fulfill the requirement created by the Affordable Care Act to revalidate Medicaid providers. CMS has provided states with direct access to Medicare's PECOS enrollment database, as well as monthly PECOS data extracts that states can use to systematically compare state enrollment records against available PECOS information. CMS assigned staff to coordinate directly with each state and is providing extensive guidance and technical assistance to assist states on their revalidation efforts.

CMS published several toolkits to help address some of the most frequent findings from state program integrity reviews in the area of provider enrollment, both in fee-for-service and managed care. The toolkits address a wide range of issues, including issues with provider disclosures of ownership and control, business transactions, and criminal convictions; federal 12 http://oig.hhs.gov/oei/reports/oei-03-13-00050.asp

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In March 2016, CMS released additional guidance in the Medicaid Provider Enrollment Compendium 14 to help states in implementing various enrollment requirements including the site visit requirements and provider ownership disclosure requirements. CMS worked with the Federal Bureau of Investigation to publish guidance to help states implement fingerprint-based criminal background checks for providers in the high risk category. 15 CMS continues to help states implement the provider ownership disclosure requirements and other requirements through regular state program integrity reviews to assess the effectiveness of states' program integrity efforts.

As discussed earlier, CMS also recently finalized a rule 16 strengthening program integrity in Medicaid managed care by identifying minimum standards for provider screening and enrollment and expanding managed care plan responsibilities in program integrity efforts.

Enrollment Moratoria CMS has used authority provided by the Affordable Care Act to impose temporary enrollment moratoria. The moratoria temporarily halted the enrollment of new home health agencies (HHAs) and ground ambulance suppliers in certain geographic areas, giving CMS the opportunity to analyze and monitor the existing provider and supplier base, as well as further focus additional fraud prevention and detection tools in these areas. CMS consulted with HHSOIG and the Department of Justice, and found that fraud trends warranted these moratoria. Part of CMS’ work included a review of key factors of potential fraud risk, including findings of a 13 https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/FraudAbuseforProfs/frequent-findingstoolkits-121714.html 14 https://www.medicaid.gov/affordablecareact/provisions/downloads/mpec-032116.pdf 15 https://www.medicaid.gov/federal-policy-guidance/downloads/smd060115.pdf 16 https://www.federalregister.gov/articles/2016/05/06/2016-09581/medicaid-and-childrens-health-insuranceprogram-chip-programs-medicaid-managed-care-chip-delivered

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Earlier this year, CMS released a Moratoria Provider and Supplier Services and Utilization Data Tool. 18 The tool uses ambulance and HHA paid claims data within CMS systems for Medicare fee-for-service beneficiaries. The data, which do not contain any individually identifiable information about Medicare beneficiaries or their providers, cover the period from October 1, 2014 to September 30, 2015, and are updated quarterly. The tool includes interactive maps and a dataset that shows national-, state-, and county-level provider and supplier services and utilization data for selected health service areas. For the first release, the data provide information on the number of Medicare ambulance suppliers and home health providers servicing a geographic region, with moratoria regions at the state and county level clearly indicated, and the number of Medicare beneficiaries who use one of these services. The data can also be used to reveal the degree to which use of these services is related to the number of providers and suppliers servicing a geographic region. Provider and supplier services and utilization data by geographic regions are easily compared using the interactive maps.





Efforts to Identify and Address Improper Payments CMS takes seriously our responsibility to limit improper payments and ensure that taxpayers’ dollars are spent wisely. It is important to remember that improper payments are not typically fraudulent payments. Rather, they are usually payments made for items or services that do not meet Medicare or Medicaid’s coverage and medical necessity criteria, that are incorrectly coded, or that do not include the necessary documentation. Correctly recording and documenting medical services is an important part of good stewardship of these programs, and we strive to improve these practices among providers serving Medicare, Medicaid, and CHIP beneficiaries.

17 https://www.federalregister.gov/articles/2016/02/02/2016-01835/medicare-medicaid-and-childrens-healthinsurance-programs-announcement-of-the-extended-temporary 18 https://data.cms.gov/moratoria-data 9 While some progress has been made, we must and we will continue our work to reduce the improper payment rates in Medicare, Medicaid, and CHIP. We experienced reductions in the Medicare-fee for service error rate from 2014 to 2015, as CMS’s “Two Midnight” rule and corresponding educational efforts led to a reduction in improper inpatient hospitals claims. The improper payment rate for durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) also decreased. Corrective actions implemented over a six-year period, including the DMEPOS Accreditation Program, contractor visits to large supplier sites, competitive bidding, and a demonstration testing prior authorization of power mobility devices, contributed to the reduction in the improper payment rate for these items and supplies.

We know we have more work to do to sustain this progress and meet improper payment rate reduction targets. One area in Medicare fee-for-service on which we are focusing our efforts is in home health services, which have had particularly high improper payment rates in recent years, mainly due to documentation errors. To address this, CMS has made changes to what providers need to submit in order to comply with our payment policies and clarified these policies for providers. CMS believes clarifying requirements will lead to a decrease in these errors and improve provider compliance with regulatory requirements, while continuing to strengthen the integrity of the Medicare program. To ensure providers understand the regulations and documentation requirements, CMS has implemented a probe and educate program for all home health agencies. This program reviews a small number of claims for every home health agency, identifies whether the reviewed claims complied with Medicare policies, and offers education to providers who require assistance in properly documenting home health claims.

CMS has also implemented additional prior authorization models to help make sure services are provided in compliance with Medicare coverage, coding, and payment rules before services are rendered and claims are paid. Through prior authorization, a request for provisional affirmation of coverage is submitted for review before a service is furnished to a beneficiary and before a claim is submitted for payment. Prior authorization does not create additional documentation requirements or delay medical service. It requires the same information that is currently necessary to support Medicare payment, but earlier in the process. Prior authorization is an 10 effective way to promote compliance with Medicare rules for some items and services and to help prevent improper payments before they occur.

In addition to certain power mobility devices (PMDs), CMS is now utilizing a prior authorization process in certain states for non-emergent hyperbaric oxygen therapy and repetitive scheduled non-emergent ambulance transports. 19 Lastly, CMS published a final regulation on December 30, 2015 establishing a prior authorization program for certain durable medical equipment, prosthetics, orthotics, and supplies items frequently subject to unnecessary utilization. 20 The Medicare Prior Authorization of PMDs Demonstration was initially implemented in California, Illinois, Michigan, New York, North Carolina, Florida, and Texas. Since implementation, we have observed a decrease in expenditures for PMDs in the demonstration states and non-demonstration states. Based on claims processed from September 1, 2012 through June 2015, monthly expenditures for the PMD codes included in the demonstration decreased from $12 million to $3 million in the seven original demonstration states, without affecting beneficiary access to appropriate services. Subsequently, we expanded the demonstration to twelve additional states 21 on October 1, 2014. Based on claims processed from September 1, 2012 through June 2015, monthly expenditures in these twelve additional states decreased from $10 million to $2 million. On July 15, 2015, we extended the demonstration for all nineteen states until August 31, 2018. Monthly expenditure also decreased in the non-demonstration states, from $10 million in September 2012 to $3 million in June 2015.22 We also have more work to do to meet error rate reduction targets in Medicare Advantage, Medicaid, and CHIP. To better address and prevent improper payments in Medicare Advantage, 19 For more information: https://www.cms.gov/Research-Statistics-Data-and-Systems/MonitoringPrograms/Medicare-FFS-Compliance-Programs/Prior-Authorization-Initiatives/Prior-Authorization-Initiatives-.html 20 https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-CompliancePrograms/Prior-Authorization-Initiatives/Downloads/DMEPOS_6050_Final_12_30_15.pdf 21 Maryland, New Jersey, Pennsylvania, Indiana, Kentucky, Ohio, Georgia, Tennessee, Louisiana, Missouri, Washington, and Arizona.

22 https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-CompliancePrograms/Medical-Review/Downloads/PMDDemoOctoberStatusUpdate10142015.pdf 11 in December 2015, CMS issued a Request for Information (RFI) 23 to solicit feedback on a proposal to contract with one or more Recovery Auditors (RA) to identify and correct improper payments in Medicare Advantage through a significantly expanded Risk Adjustment Data Validation (RADV) audit initiative. As a result of existing RADV audits and new regulations requiring Medicare Advantage organizations to report and return identified overpayments, during FY 2015, Medicare Advantage Organizations reported and returned approximately $650 million in overpayments.

Medicaid and CHIP also experienced increases with their improper payment rates from fiscal year 2014 to 2015. Similar to FY 2014, the primary reason for the increase was related to state difficulties bringing systems into compliance with certain requirements, including that all referring or ordering providers be enrolled in Medicaid and that states screen providers under a risk-based screening process prior to enrollment. While these requirements will ultimately strengthen Medicaid’s integrity, it is not unusual to see increases in improper payment rates following the implementation of new requirements because it takes time for states to make systems changes required for compliance.

Conclusion CMS is deeply committed to our efforts to prevent waste, fraud and abuse in Medicare and Medicaid programs, protecting both taxpayers and the beneficiaries that we serve. The GAO and HHS-OIG are critical partners in these continuous improvement efforts, and both programs are stronger today as a direct result of their insights. We look forward to continuing our partnership with GAO and OIG to work together on additional ways to identify and eliminate vulnerabilities and to strengthen both of these programs.

23 https://www.fbo.gov/index?s=opportunity&mode=form&id=83f1ec085c52a81a6a6ce7cba3ffbc5d&tab=core&_cvie w=0

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