New Affordable Care Act Rules to Fight Healthcare Fraud On Mon Jan 24, HHS announced new rules authorized by the Affordable Care Act which will help stop healthcare fraud. "Thanks to the new law, CMS now has additional resources to help detect fraud and stop criminals from getting into the system in the first place," CMS Administrator Donald Berwick, MD, said. "The Affordable Care Act's new authorities allow us to develop sophisticated, new systems of monitoring and oversight to not only help us crack down on fraudulent activity scamming these programs, but also help us to prevent the loss of taxpayer dollars across the board for millions of American healthcare consumers."
Specifically, the final rule: * Creates a rigorous screening process for providers and suppliers enrolling Medicare, Medicaid, and CHIP to keep fraudulent providers out of those programs. Types of providers and suppliers that have been identified in the past as posing a higher risk of fraud (for example, durable medical equipment suppliers) will be subject to a more thorough screening process. * Requires new enrollment process for Medicaid and CHIP providers. Under the Affordable Care Act, states will have to screen providers who order and refer to Medicaid beneficiaries to determine if they have a history of defrauding the government. Providers that have been kicked out of Medicare or another state's Medicaid or CHIP will be barred from all Medicaid and CHIP programs. * Temporarily stops enrollment of new providers and suppliers. Medicare and state agencies will be on the lookout for trends that may indicate healthcare fraud - including using advanced predictive modeling software, such as that used to detect credit-card fraud. If a trend is identified in a category of providers or geographic area, the program can temporarily stop enrollment as long as that will not impact access to care for patients. * Temporarily stops payments to providers and suppliers in cases of suspected fraud. Under the new rules, if there has been a credible fraud allegation, payments can be suspended while an action or investigation is underway. For more information: § The full text of the press release issued on Mon Jan 24 is available at http://www.HHS.gov/news/press/2011pres/01/20110124a.html<http://www.hhs.gov/news/press/2011pres/01/20110124a.html>. § A copy of the regulation is available in the Federal Register at www.OFR.gov/inspection.aspx<http://www.ofr.gov/inspection.aspx> or www.archives.gov/federal-register/news.html<http://www.archives.gov/federal-register/news.html>. § A factsheet on the new rules can be found at www.HealthCare.gov/news/factsheets<http://links.govdelivery.com/track?type=click&enid=bWFpbGluZ2lkPTExODM1ODQmbWVzc2FnZWlkPVBSRC1CVUwtMTE4MzU4NCZkYXRhYmFzZWlkPTEwMDEmc2VyaWFsPTEyNzY3Mzc5MzcmZW1haWxpZD1saXNhLnNtaXRoQGNtcy5oaHMuZ292JnVzZXJpZD1saXNhLnNtaXRoQGNtcy5oaHMuZ292JmZsPSZleHRyYT1NdWx0aXZhcmlhdGVJZD0mJiY=&&&106&&&http://www.healthcare.gov/news/factsheets>. --------------------------------------------------------------------------------------------------------------------------------------------- Critical Access Hospitals to Receive Free Comparative Data Reports Beginning in April 2011, the Centers for Medicare & Medicaid Services will make available free hospital-specific comparative data reports for critical access hospitals (CAHs) nationwide. The report - known as PEPPER, or the "Program for Evaluating Payment Patterns Electronic Report" - provides hospital-specific data statistics for Medicare discharges at risk for improper payments. Hospitals can use the data to support internal auditing and monitoring activities. PEPPER is the only free report comparing a CAH's Medicare billing practices with other CAHs in the state, MAC or FI (Medicare Administrative Contractor or Fiscal Intermediary) jurisdiction, and nation. CMS has contracted with TMF Health Quality Institute to develop and distribute the reports, which were previously available only for short- and long-term acute care hospitals. The PEPPERs will be distributed via a MyQualityNet secure file exchange on or about Mon Apr 25. (MyQualityNet is a secure site accessible from the www.QualityNet.org<http://www.qualitynet.org/>; CAHs must have a QualityNet account in order to receive their PEPPER.) The PEPPER files will be sent to the hospital's QualityNet administrators and to QualityNet user accounts with the PEPPER recipient role. CAHs may work with their Quality Improvement Organization if they do not have a QualityNet administrator account. For more information, including the PEPPER distribution schedule, a sample of the PEPPER for CAHs, and information about QualityNet accounts, visit www.PEPPERresources.org<http://www.pepperresources.org/>. CAH staff are also encouraged to join the email list on this website to receive important notifications about upcoming PEPPER distribution and training opportunities. --------------------------------------------------------------------------------------------------------------------------------------------- January Flu Shot Reminder Get Your Flu Vaccine - Not the Flu. Don't forget to immunize yourself and your staff. Protect your patients. Protect your family. Protect yourself. While seasonal flu outbreaks can happen as early as October, flu activity usually peaks in January. This year's vaccine will protect against three different flu viruses, including the H1N1 virus that caused so much illness last flu season. The risks for complications, hospitalizations, and deaths from the flu are higher among individuals aged 65 years and older. Medicare pays for the seasonal flu vaccine and its administration for seniors and others with Medicare with no co-pay or deductible. Health care workers, who may spread the flu to high-risk patients, should get vaccinated too. Remember - Influenza vaccine plus its administration are covered Part-B benefits. (Note that influenza vaccine is NOT a Part-D-covered drug.) For information about Medicare's coverage of the influenza vaccine and its administration, as well as related educational resources for health care staff, please visit http://www.cms.gov/MLNProducts/Downloads/Flu_Products.pdf and http://www.cms.gov/AdultImmunizations. --------------------------------------------------------------------------------------------------------------------------------------------- Note: If you have problems accessing any hyperlink in this message, please copy and paste the URL into your Internet browser. Please DO NOT respond to this email. This email is a service of CMS and routed through an electronic mail server to communicate Medicare policy and operational changes and/or updates. Responses to this email are not routed to CMS personnel. Inquiries may be sent by going to (http://www.cms.hhs.gov/ContactCMS). Thank you. 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