In its transition from "pay and chase" to fraud prevention, CMS has published its Final Rule, which governs payment suspension, screening requirements and other anti-fraud measures under the Patient Protection and Affordable Care Act, according to a report from ReedSmith.
The rule, which establishes complex and new anti-fraud regulations, is effective March 25. CMS is delaying one provision regarding fingerprinted criminal history record checks for certain providers.
The final rule applies screening tools such as unannounced site visits, background checks and fingerprinting to help prevent fraud. It also delineates three levels of risk — limited, moderate or high — to which providers are assigned. The rule also authorizes the suspension of Medicare payments to a provider or supplier pending an investigation of a credible allegation of fraud, according to the report. These "credible allegations" include those from any source, including but not limited to fraud hotline complaints, claims data mining, audit patterns, civil false claims cases and law enforcement investigations.
Under the final rule, "institutional providers" will fund these screening and integrity efforts through a $505 fee for 2011, updated annually for inflation. CMS will begin collecting the application fee March 23. CMS estimates these application fees will total approximately $304.5 million over the next five years.
Read the ReedSmith report on the final rule.
Read more about healthcare fraud:
- Feds Charge 111 in Largest Healthcare Fraud Takedown To Date
- OIG Releases List of 10 Most-Wanted Healthcare Fraudsters
The rule, which establishes complex and new anti-fraud regulations, is effective March 25. CMS is delaying one provision regarding fingerprinted criminal history record checks for certain providers.
The final rule applies screening tools such as unannounced site visits, background checks and fingerprinting to help prevent fraud. It also delineates three levels of risk — limited, moderate or high — to which providers are assigned. The rule also authorizes the suspension of Medicare payments to a provider or supplier pending an investigation of a credible allegation of fraud, according to the report. These "credible allegations" include those from any source, including but not limited to fraud hotline complaints, claims data mining, audit patterns, civil false claims cases and law enforcement investigations.
Under the final rule, "institutional providers" will fund these screening and integrity efforts through a $505 fee for 2011, updated annually for inflation. CMS will begin collecting the application fee March 23. CMS estimates these application fees will total approximately $304.5 million over the next five years.
Read the ReedSmith report on the final rule.
Read more about healthcare fraud:
- Feds Charge 111 in Largest Healthcare Fraud Takedown To Date
- OIG Releases List of 10 Most-Wanted Healthcare Fraudsters