CMS seeks help stopping fraudsters before they act

The CMS is in the early stages of searching for a contractor that would orchestrate an integrated outreach effort across Medicare, Medicaid and other federal healthcare programs to prevent fraud before it happens.

The CMS now relies on a series of contractors to perform outreach efforts for particular stakeholders and programs. But the agency has found this approach to be unsuccessful.

“This approach leaves a large group of CMS' stakeholder education and outreach needs unmet, the agency says in a request for information (PDF) notice.

“These programs have grown and changed exponentially. Therefore, the CMS is integrating the education and outreach needs of these programs along with the education and outreach needs of the other stakeholders whose needs are not being met,” the agency says.

The purpose of the RFI is to gauge whether there any companies that have the ability and qualifications to fulfill the duties outlined in the document. Responses are due March 7. Depending on responses, a formal request for proposals would be released at a later date.

Having an integrated outreach approach should make it easier to identify bad actors or potential bad actors more quickly, according to the agency. The contractor would be expected to implement “a powerful new tactic” the CMS calls intervention.

“This will allow CMS to act with pinpoint precision and reach small selected groups that are in danger of being out of compliance or performing wasteful and abusive billing actions before they become fraudulent or noncompliant,” the agency says.

Intervention tactics could include personalized visits, letters or phone calls, small educational seminars, or local geographically focused speaking events.

The agency doesn't describe in the document how a contractor might accomplish the feat of spotting individuals and organizations likely to engage in fraudulent or abusive billing.

Virgil Dickson

Virgil Dickson reports from Washington on the federal regulatory agencies. His experience before joining Modern Healthcare in 2013 includes serving as the Washington-based correspondent for PRWeek and as an editor/reporter for FDA News. Dickson earned a bachelor's degree from DePaul University in 2007.

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