CMS stops taking new provider applications in fraud zones

The Centers for Medicare & Medicaid Services extended last year's moratoria on new enrollments for home healthcare and ground ambulance providers in three fraud-prone cities while unveiling new moratoria on similar providers elsewhere, the agency announced yesterday.

CMS is temporarily refusing to let new providers bill Medicare, Medicaid and the Children's Health Insurance Program in places where a disproportionate number of like specialists already generate excessive claims expense. Both the new moratoria and the six month extension take effect Jan. 31.

Extended moratoria apply to homecare providers in Chicago and Miami and ambulance providers in Houston. Cities affected by the new home health agency provider ban include Dallas; Detroit; Houston; and Fort Lauderdale, Fla. And no new ground ambulance providers will get billing privileges for the next six months in Philadelphia.

Instead of creating gigantic open networks that let criminals in, CMS is controlling who's allowed to bill government health insurance programs in areas of fraud vulnerability. It's a preemptive move to obviate pay-and-pursue efforts later, the agency noted.

"Our first use of the moratoria put fraudsters on notice that we are using all available tools ... to combat fraud, waste, and abuse in our healthcare programs," CMS Administrator Marilyn Tavenner said Thursday in the announcement. "Today's announcement shows we are continuing our intense fight against fraud, waste and abuse in these vital healthcare programs."

Fraud and abuse schemes involving home healthcare abound. Some providers falsify information sent to Medicare to collect payment for patients not certified as homebound by their doctors, for example. Agencies also may bill for services other than therapies approved for coverage under Medicare's home care benefit.

Congress criticized CMS for past reluctance to impose new provider moratoria to fight fraud, as FierceHealthcare previously reported; but then and now, the agency insists this anti-fraud tactic shouldn't be used before carefully assessing effects of moratoria on access to care.

For more:
- read the CMS announcement

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