Medicare plans to start ejecting providers with patterns of abusive billing, prompting physician organizations to question how the government will avoid snagging honest providers in the dragnet.
The CMS finalized the policy and other new anti-fraud measures in a rule issued Wednesday that stems from provisions of the Patient Protection and Affordable Care Act. The agency will deny or revoke Medicare billing privileges from providers and that routinely bill for services that don't meet Medicare requirements.
“We haven't heard from the CMS what defines a pattern or practice of inappropriate billing,” said Dr. Wanda Filer, president-elect at the American Academy of Family Physicians. “The concern is that because the schema is so complex, someone could make an error and we want to make sure everyone is not overly adjudicated without some due process. We want to make sure patients don't get harmed by this.”
The trade group raised this issue when the policy was introduced in the proposed rule. The CMS, according to the AAFP, responded that the agency wanted to maintain flexibility by not defining what the rule refers to as "a pattern or practice" of claims that don't meet Medicare rules.
A CMS spokesman did not immediately respond to a request for comment.
The American Medical Association raised similar concerns.
“Federal initiatives for eliminating Medicare fraud and abuse need to acknowledge that inadvertent errors and interpretation differences are inevitable when complex medical services are billed to Medicare,” said AMA President Dr. Robert Wah. “Failing to make this important distinction invites intimidation of honest physicians.”
Both groups, however, say they generally support any effort to cut down fraud in Medicare because most providers are honest in their dealings with the Medicare program.
In addition to dumping providers from Medicare for inappropriate billing practices, the CMS will now reject providers and suppliers seeking to enroll if they're affiliated with any entity that has unpaid Medicare debt. The policy is intended to stop people and businesses from exiting the program and then re-enrolling as a new business to avoid paying what they owe.
The agency is also now going to deny or revoke Medicare billing privileges from providers and suppliers if a managing employee has been convicted of a felony offense that the CMS determines is detrimental to Medicare beneficiaries.
Finally, a provision of the rule makes billing privileges consistent across provider types. This provision alone is estimated to save $327 million annually. It will end a policy that allowed ambulance services to bill Medicare for up to a year before enrolling in the program. It also requires that ambulance providers and other provider and supplier types submit any remaining claims within 60 days after their privileges are revoked.
Since the creation of Medicare in 1966 the CMS has removed nearly 25,000 providers from the program for a variety of inappropriate activity, according to the agency.
“The new rules help us stop bad actors from coming back in as we continue to protect our patients,” Dr. Shantanu Agrawal, a CMS deputy administrator and director of the Center for Program Integrity, said in a statement. “For years, some providers tried to game the system and dodge rules to get Medicare dollars.”
The CMS struggled to come up with an estimate for how much the entire 140-page rule could ultimately save the government. The agency also said it doesn't have an estimate of providers that could be affected by the new rules because of outstanding Medicare debts, felony convictions or patterns of abusive billing.
The rule comes a day after House Ways and Means Health Subcommittee Chairman Kevin Brady (R-Texas) and Rep. Jim McDermott (D-Wash.), the committee's ranking member, introduced the Protecting the Integrity of Medicare Act of 2014, which aims to reform Medicare's anti-fraud programs and emphasizes preventing fraud, waste and abuse before it happens over recovering the money after Medicare pays the claims.
Follow Virgil Dickson on Twitter: @MHvdickson