CMS unveils 5 'pillars' to curbing fraud, waste in Medicare 

File folders labeled "insurance," "fraud," "claims," and "under investigation"
The Centers for Medicare & Medicaid Services is building a multipoint approach to curbing Medicare fraud. (Getty Images/Olivier Le Moal)

To curb Medicare fraud, the Trump administration is designing a five-pronged integrity strategy for the program. 

Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma unveiled the effort in a blog post Monday afternoon. The goal, Verma said, is to work on multiple fronts to “modernize our approach and protect Medicare for future generations.” 

Doing more to address fraud, waste and abuse in Medicare was one of several provisions included in an executive order on the program that was signed by President Donald Trump earlier this month

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RELATED: CMS gets new powers to go after Medicare, Medicaid fraudsters

Verma said adjusting the strategy has become increasingly important as Medicare has launched a diverse array of value-based payment models and now covers new types of providers, such as home health and federally qualified health centers.  

“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 intent, improperly seek payment from our programs,” Verma wrote. “They necessitate a paradigm shift in how we approach program integrity.” 

The five “pillars” of the program, Verma wrote, are: 

  1. Stopping bad actors. The agency will work alongside law enforcement to identify and prosecute fraudulent behavior quickly. 

  1. Fraud prevention. CMS will make systemic changes after fraud is identified to ensure similar schemes don’t happen in the future, Verma said. CMS is also working to preemptively identify problems or high-risk areas and make policy changes to address them. 

  1. Tracking “new and emerging” risks. Tackling fraud is like playing a game of whack-a-mole, Verma wrote—new risks pop up as others are addressed. CMS has taken steps such as continued use of prior authorization and value-based models in Medicare Advantage to be proactive. 

  1. Ease provider burdens. CMS has made provider burden a key focus under Trump, Verma said. Streamlining administrative work can prevent fraud by eliminating clerical errors. 

  1. Take advantage of new technology. CMS wants to harness emerging tech platforms to automate and modernize its program integrity efforts. 

RELATED: CMS launches slate of initiatives aimed at curbing fraud, waste in Medicaid 

Alongside the blog post, CMS released two requests for information (RFIs) to gather feedback on ways it can further these efforts. In the first, it is seeking comments on ways it can most effectively take advantage of technology to improve its programs combating fraud or to ease the burdens on providers. 

“CMS must elevate program integrity, unleash the power of modern private sector innovation, prevent rather than chase fraud waste and abuse through smart, pro-active measures, and unburden our provider/supplier partners so they can do what they do best—put patients first,” the agency wrote in the RFI. 

CMS will accept comments until Nov. 20. 

The second RFI seeks feedback on the agency’s program integrity efforts as a whole and will also accept responses through Nov. 20. 

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