Healthcare Business News

Late News: After opposition, CMS stalls two anti-fraud projects

By Modern Healthcare
Posted: January 2, 2012 - 12:01 am ET

The CMS delayed two anti-fraud demonstration projects that drew heavy provider opposition after they were announced in November, according to a notice on the agency’s website.

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One pilot would require prior authorization for scooters and power wheelchairs prescribed for Medicare beneficiaries living in any of the seven states with the highest concentration of fraud or billing errors: California, Illinois, Michigan, New York, North Carolina, Florida and Texas.

The preauthorization process was devised to ensure that medical conditions warrant the medical equipment, according to the CMS. Another delayed project would allow recovery audit contractors to review claims before they are paid, focusing on the types of claims historically associated with high rates of improper payments in seven states (Florida, California, Michigan, Texas, New York, Louisiana and Illinois) and claims with high volumes for short inpatient hospital stays in four states (Pennsylvania, Ohio, North Carolina and Missouri).

CMS officials said the RAC expansion would lower Medicare’s error rate by preventing improper payments, rather than the traditional “pay and chase” methods of looking for improper payments after they occur. The agency plans to provide at least 30 days’ notice before the delayed demonstration projects begin. A third demonstration program announced at the same time was slated to begin, as planned, on Jan. 1. It will allow hospitals to re-bill for 90% of the Part B payment they would have received for claims a Medicare contractor denied for care billed as short inpatient stays.

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