Senate Finance, House W&M and E&C Leaders Call on CMS to Prevent Fraudulent Medicare Spending
The letter was sent by Finance Chairman
Members explained that CMS still relies too heavily on the outdated "pay and chase" practice - paying a claim before investigating whether it was fraudulent. Expressing the need to end "pay and chase" and strengthen the Fraud Prevention System (FPS), the Members wrote:
"The billions of dollars lost to
The Members specifically requested for CMS to clarify the Agency's implementation of the FPS program, including details on fraud investigations and how the Agency monitors FPS's effectiveness.
Go to: http://waysandmeans.house.gov/wp-content/uploads/2016/09/20160912-FPS-2-letter-to-CMS.pdf to read the letter. Full text of the letter is below
Mr. Andrew Slavitt
Acting Administrator
Dear Mr. Slavitt:
The billions of dollars lost to
Improper payments remain an enormous problem for the Medicare Program. In 2015, the Medicare Fee-for-Service Program had an error rate of 12.1 percent, or
According to Dr.
We remain supportive of CMS' efforts to implement the FPS, but are concerned that the FPS continues to rely primarily on outdated "pay and chase" activities rather than focusing on preventing potentially fraudulent dollars from going out in the first place. To assist our Committees in understanding CMS' work implementing the FPS, please provide the following information, no later than
A breakdown on the types of schemes and impacted
1. The top ten allegation categories (e.g., upcoding and billing for services not rendered) and top five impacted
2. The number of FPS leads that lead to the creation of new ZPIC investigations. Did these investigations result in any actions taken by CMS? If so:
1. How many investigations resulted in actions by CMS?
2. What actions were taken?
3. What was the dollar amount involved?
The number of FPS leads that aided existing ZPIC investigations. Did these investigations result in any actions taken by CMS? If so:
1. How many investigations resulted in actions by CMS?
2. What actions were taken?
3. What was the dollar amount involved?
How many total investigations were conducted by ZPICs over the past three years? Please specify:
1. What percentage of ZPIC investigations were supported by FPS leads?
2. How many actions were taken by CMS resulting from ZPIC investigations? Please include: the number of investigations that resulted in actions by CMS, the types of actions, and the dollar amounts involved.
The types of edits and/or filters that have been put into place as a result of the FPS over the past 3 years? Please specify:
1. The various edit/filter categories for existing edits/filters.
2. How many improper claims have been stopped due to these edits and what are the dollar amounts involved?
3. For edits established by contractors other than the FPS contractors, please explain how the FPS contributed to the edit put into place.
4. How many claims in the past 3 years have been stopped by algorithmic models and not pre-pay edits and denied before payment was made?
With guidance from the OIG, CMS developed adjustment factors to identify amounts saved or returned to the
The total amount obligated over the past 3 years for FPS and the ZPICs.
A description of the process currently in place to monitor the effectiveness of the FPS models. How does CMS verify that models in the FPS are working as intended?
Thank you in advance for your assistance in this matter.
Read this original document at: http://www.finance.senate.gov/chairmans-news/senate-finance-house-wandm-and-ec-leaders-call-on-cms-to-prevent-fraudulent-medicare-spending
Advisor News
Annuity News
Health/Employee Benefits News
Life Insurance News