October 21, 2019
By Seema Verma, Administrator, Centers for Medicare & Medicaid Services
The Future of Medicare Program Integrity
Earlier this month, President Trump announced an Executive Order charging CMS to propose annual changes to combat waste, fraud, and abuse in the Medicare program. That’s why I’m proud to announce our vision to modernize our program integrity methods to better protect taxpayers from fraud, waste and abuse in Medicare. Every dollar spent on Medicare comes from American taxpayers and must not be misused.
CMS defines program integrity very simply: “pay it right.” Program integrity must focus on paying the right amount, to legitimate providers, for covered, reasonable and necessary services provided to eligible beneficiaries while taking aggressive actions to eliminate fraud, waste and abuse. Our health care programs are quickly evolving; therefore our program integrity strategy must keep pace to address emerging challenges.
Government watchdogs routinely identify concerns about waste and abuse within our programs. The Government Accountability Office (GAO) has designated Medicare as a High Risk program since 1990 because of its size, complexity and susceptibility to improper payments. In 2018, improper payments accounted for 5% of the total $616.8 billion of Medicare’s net costs. While CMS regularly implements GAO recommendations, sometimes we lack the tools or capabilities to integrate worthy suggestions. The Medicare Fee-For-Service (FFS) program is limited by statute as to what methods can be used to prevent fraud, waste, and abuse. For example, last year’s President’s budget contained a legislative proposal to expand review of high risk areas in FFS. Under current statute, review is limited to durable medical equipment like wheelchairs. In contrast, other programs like Medicaid, Medicare Advantage, Medicare Prescription Drug Plans (PDPs), Tricare, Marketplace plans, and private insurers all have broad authority to review procedures for medical necessity and appropriateness. GAO has also recommended that Congress expand prior authorization in FFS.
As our programs become more complex, program integrity risks become increasingly difficult to recognize. New provider types have entered the program, including hospices, home health agencies, and federally qualified health centers. CMS has implemented a number of value-based payment programs that have improved quality and managed cost, but also bring new challenges in identifying improper payments, beneficiary safety and quality issues, and other program integrity concerns. More challenging cross-ownership issues have emerged, such as one corporate parent owning various providers and provider types. Increasingly complex webs of affiliations can allow unscrupulous providers to simply appear, disappear if they come under scrutiny, and then re-appear as “new” entities.
Medicare’s transformation has raised the stakes of program integrity to historically high levels — taxpayers have more to lose than ever before from those who would, whether by negligence or by intent, improperly seek payment from our programs. They necessitate a paradigm shift in how we approach program integrity.
When Medicare was signed into law 54 years ago, there were only 19 million beneficiaries. Today, there are almost 61 million and we are adding 10,000 new enrollees every day. When the programs began, Medicare and Medicaid accounted for only 2.3% of Federal spending. These government programs now account for 23.5% of Federal spending. We have witnessed exponential growth in the number and types of providers included, the types of benefits available, the number of claims processed and paid, and, perhaps most importantly, the number of dollars involved.
Medicare’s improper payment rates have declined but remain too high. That’s why CMS is developing a five-pillar program integrity strategy to modernize our approach and protect Medicare for future generations.
CMS integrates various processes to identify and mitigate vulnerabilities before exposure to protect proactively people with Medicare. For example, to mitigate risks during the recent efforts to send new Medicare cards to beneficiaries, CMS implemented an enhanced address validation process to verify beneficiaries’ identities and addresses against multiple information sources. This ensured that we mailed new Medicare cards to the right person at the right address. We reviewed over 61 million cards for address accuracy, which we estimate saved billions of dollars in fraudulent claim payments.
An important aspect of fraud prevention is having various sources of information. CMS relies on important partnerships to share data and information that help narrow down on potential areas of concern. One of our most critical relationships is the Healthcare Fraud Prevention Partnership (HFPP). This is a voluntary, public-private partnership between Federal government, state and local agencies, law enforcement, private health insurance plans, employer organizations, and healthcare anti-fraud associations that come together to collaboratively identify and reduce fraud, waste, and abuse across the healthcare sector. We use this partnership for stakeholder engagement and to share information and leads across partners. The leads are used to conduct various studies and the results help CMS identify potential issues that may not have otherwise been caught. Currently there are 144 partners and counting. The more members we have, the more data is gathered, and the better insights we have into fraud across the entire healthcare system.
We are also addressing potential healthcare fraud by targeting high-risk areas and implementing policy changes. In September, CMS issued a first-of-its-kind final rule, Program Integrity Enhancements to the Provider Enrollment Process (CMS-6058-FC), which will reduce criminal behavior across our programs. This rule applies proactive methods to keep unscrupulous providers and suppliers out of Medicare and Medicaid from the outset and enhances our ability to promptly identify and act on instances of improper behavior – helping us to stop fraud before it happens. It creates several new revocation and denial authorities to bolster CMS’ efforts to stop fraud, waste and abuse. Importantly, a new “affiliations” authority in the rule allows CMS to identify individuals and organizations that pose an undue risk of fraud, waste or abuse based on their relationships with other previously sanctioned entities. This rule marks a critical step forward in CMS’ longstanding fight to end “pay and chase” in Federal healthcare fraud efforts and replace it with smart, effective and proactive measures.
Looking forward, we are looking to add private sector technology tools to complement our fraud prevention analytics so our future capabilities will be faster, smarter and more robust.
We also are using demonstrations to test new approaches for high vulnerability services such as home health. The Review Choice Demonstration for Home Health Services illustrates how CMS is working proactively to identify and prevent fraud in an area with high improper payment rates while minimizing unnecessary provider burden. The demonstration helps ensure that the right payments are made at the right time for home health services but allows providers the flexibility to choose what works best for them. This protects Medicare funding from improper payments, reduces the number of Medicare appeals, and improves provider compliance with Medicare program requirements. In response to stakeholder feedback, this demonstration incorporates more flexibility and choice for providers on how their claims are reviewed, as well as risk-based changes to reduce burden on providers demonstrating compliance with Medicare home health policies.
More recently, Medicare Advantage enrollment continues to grow and we have added many value-based payment programs as part of our strategy to improve how healthcare is delivered and paid for in the Medicare program. New payment models have been very beneficial but also have the potential to cause new challenges in identifying improper payments, beneficiary safety issues, and other program integrity concerns. CMS is continuing to explore ways to identify and reduce program integrity risks related to value-based payment programs by looking to experts in the healthcare community for lessons learned and best practices.
The TPE program has also highlighted provider burden and confusing policies. The Medicare documentation requirements appear in various locations and on separate websites, causing burden to providers who must navigate the various websites to find coverage rules, including documentation and prior authorization requirements. That’s why CMS is collaborating with ongoing industry efforts to streamline workflow access to coverage requirements, starting with developing a prototype Medicare FFS Documentation Requirement Lookup Service. This initiative will allow providers to discover Medicare FFS prior authorization and documentation requirements at the time of service and within their EHR.
The initiatives above are a few of many projects we have to reduce provider burden. For example, we’re proposing to eliminate “certification statements” for some hospital transfers. These statements add time and burden and are often duplicative with other required documents. In addition, we’re changing our practices to focus more on problematic billing, not all billing. For example, we’re proposing to reduce DMEPOS prior authorization for some providers who demonstrate good billing practices. If they do a good job, we don’t need to make them jump through more hoops because others may not.
CMS also has vigorous provider screening and enrollment tools at our disposal to prevent fraud schemes. However, we believe that there is a tremendous opportunity for the Federal government and private plans to improve the provider enrollment experience. CMS is currently exploring ways to centralize screening and continuous monitoring for all payers. Cumulatively, these efforts are defining a new approach to program integrity that reduces burden and increases education to achieve a better shared understanding of how the programs operate.
We currently use sophisticated systems such as the Fraud Prevention System, and case management systems that use predictive analytics to identify abnormal trends and billing patterns, investigate abnormalities to find the root cause, act quickly to address any potential fraud, and capture fraudulent behavior. While these systems have helped us to obtain a positive return on investment, we believe that by adopting cutting edge technology – such as AI and machine learning tools — we can achieve greater savings for taxpayers and allow us to review more claims. These innovations could be used in both our current payment models, as well as in new payment models.
RFI: Using Advanced Technology in Program Integrity: https://www.cms.gov/About-CMS/Components/CPI/Downloads/Center-for-Program-Integrity-Advanced-Technology-RFI.pdf
The Future of Medicare Program Integrity
As part of CMS’s program integrity strategy to leverage new technology, CMS seeks to hear from providers, innovators, and private insurers on ways CMS can advance and modernize efforts to combat Medicare fraud, waste, and abuse (FWA) through innovation. Today CMS is issuing two Requests for Information (RFIs) asking for input from the healthcare community on the program integrity challenges involved in the transition from a fee-for-service system to value based care. We are also requesting input on new techniques and approaches involving advanced data analytics and artificial intelligence. During the RFI comment period, CMS will be holding a series of listening sessions across the country soliciting ideas and feedback on how to tackle the enduring issues plaguing our efforts to “pay it right.”
Simply stated, CMS must elevate program integrity, unleash the power of modern private sector innovation, prevent rather than chase fraud waste and abuse through smart, proactive measures, and unburden our provider partners so they can do what they do best – put patients first. For these very important reasons, we seek and welcome input and expertise from all stakeholders on how to best improve our program integrity strategy and tools as we strive to protect both taxpayer dollars and the health and well-being of beneficiaries.
RFI: The Future of Program Integrity: https://www.cms.gov/About-CMS/Components/CPI/Downloads/Center-for-Program-Integrity-Future-of-PI-RFI.pdf
ODP Announcement 19-138 provides guidance to providers regarding the process ODP staff will utilize in making a determination for Approved Program Capacity (APC) and Noncontiguous Clearance through the updated form.
Since the release of the Request for APC and Noncontiguous Clearance form and instructions with ODP Communication 071-18, additional changes have been made to align with requirements in the Consolidated, P/FDS, and Community Living Waivers, as well as changes in regulatory requirements. Specifically, the form and instructions have been updated to include requests for Reserved Capacity as enumerated in 55 Pa. Code §6100.55. In addition, the Request for APC and Noncontiguous Location Clearance form has been streamlined based on feedback from providers, and now captures whether providers are completing the form for revalidation purposes where APC documentation is required.
ODP also has developed the following documents for use in coordination with this policy.
This communication obsoletes:
Send questions via email here.
ODP Announcement 19-133 announces the next Certified Investigator (CI) Forum offered by ODP and Temple University. These forums are an opportunity for current Certified Investigators and other interested parties to receive up to date information about the Certified Investigator Program. The next session is scheduled for November 8, 2019.
There will be two sessions available during the day. If desired, participants may register for both sessions. CI program updates will be the same but other content will be dependent on participant inquiries. Participants can submit questions via email prior to the session until Tuesday, November 5. See announcement for registration information.
ODP Announcement 19-136 announces that the amendment for the Adult Autism Waiver was submitted to CMS on October 15, 2019. The submitted waiver includes modifications that were made as a result of the comments received by 37 individuals, families, agencies, and organizations. The full waiver application, as well as a side-by-side of substantive changes made as a result of public comment, is available online here.
CMS has 90 days to review the amendment and changes may occur to the content based upon discussion with CMS during the approval process. It is anticipated that the waiver amendment will be approved and effective January 1, 2020. ODP will inform all stakeholders when CMS has officially approved the Adult Autism Waiver and will make the approved waiver available at that time. Questions about this communication should be directed to Laura Cipriani.
The Harry M. Settlement Agreement was approved by a federal court judge on August 20, 2013. The Agreement ensures that Pennsylvanians who are d/Deaf and are enrolled in the Consolidated Waiver are provided with necessary communication supports and services based on their assessed needs. Among other requirements, the Agreement requires:
Questions about this communication and/or the attached documents should be directed to the ODP Deaf Services Mailbox or to the appropriate ODP Regional Office. This announcement obsoletes Announcement 099-16.
ODP Announcement 19-134 is specifically directed to Residential Providers. The Health Risk Screening Tool (HRST) is a web-based instrument used to detect health risks and destabilization early and to prevent deaths among members of vulnerable populations. The announcement lists the dates and locations of the Clinical Reviewer sessions scheduled for November. Lunch is “on your own.” All sessions run 9:00 am to 4:30 pm.
HRS, Inc., in collaboration with the Office of Developmental Programs (ODP) is announcing face to face HRST training for clinical reviewers. This is a reminder that this is the FINAL OPPORTUNITY for 2019. An email containing a link to register for the sessions will be sent directly by HRS, Inc. The sessions for Clinical Reviewers are open to registered nurses (RNs) only. These Clinical Reviewer sessions are mandatory for any RN who will perform clinical reviews. Providers should ensure that RNs who will perform the clinical reviews plan to attend one of the sessions in November if they have not already participated in one of the sessions held in August, September, or October.
To participate in the face to face training, you must have completed the HRST online rater training (ORT). Please see ODP Announcement 19-052, Health Risk Screening Tool Implementation, for information about the online training.
Clinical Reviewers will receive registration information directly from HRST online but may also contact them via email for any questions concerning the training or registration information.
ODP Announcement 19-128 shared updated information regarding a webinar “Using CDS to Support More Culturally Responsive Organizations.” The College of Direct Support (CDS) is a nationally accredited, curriculum-based learning management system that provides tools for Direct Support Professionals (DSPs), frontline supervisors, and managers supporting individuals with disabilities in community settings, as well for self-advocates and their families to create lives of independence and inclusion.
Cultural competence is a way of doing business. Organizations that operate in a culturally competent way are better at supporting people they already serve as well as reaching new customers. They create better work environments for their employees, which enables the organizations to attract and retain employees as well. Finally, culturally competent services are person-centered-services.
This course was produced by the Institute on Community Integration, University of Minnesota in collaboration with Direct Course, the producer of CDS. The live webinar was held on October 11, 2019, and the recorded webinar will be available via the following link: Recording of Using CDS to Support More Culturally Responsive Organizations. The recording will be posted on MyODP one week after the air date of the webinar.
Office of Developmental Programs (ODP) Announcement 19-132 provides information regarding trainings scheduled for October 2019 that will provide high level overviews of the ODP Regulation Package. The trainings will help to explain updates to regulations affecting individuals with intellectual disabilities or autism. The ODP Regulation Package published in the Pennsylvania Bulletin on October 5, 2019, represents the most dramatic changes in the past 30 years to our service system. The trainings scheduled for October are structured to help stakeholders understand the major changes and how they impact the system. More trainings are in development on specific topics and requirements contained in the ODP Regulatory Package. ODP will send updates to this announcement as new trainings pertaining to the ODP Regulatory Package are offered.
Along with the communication are flyers advertising the various trainings available (see below). Registration is limited to 500 people, so ODP asks that groups of people call in together when possible. The sessions will be recorded, so that a session for each topic is available on MyODP for those who are unable to take part in the live session.
The webinars are scheduled for Thursday, October 17, 3:00 pm – 4:00 pm; Friday, October 18, 2:00 pm – 3:00 pm; and Friday, October 25, 12:00 pm – 1:00 pm.
Those attending RCPA’s IDD Division meeting on 10/17/19 are invited to stay after the meeting to participate in the webinar that begins at 3:00 pm.
OVR is offering six webinars beginning October 2019 and scheduled through December 2019. Each webinar addresses different topics regarding the Pre-Employment Transition Services (PETS) offered in Pennsylvania: