News: CMS adopts five-part strategy to address Medicare fraud, waste, and abuse
CMS announced a five-part strategy to combat fraud, waste, and abuse in the Medicare system, HealthLeaders Media reported.
About 25% of U.S. healthcare spending is wasteful, according to a recent article published in the Journal of the American Medical Association (JAMA). The researchers focused on six categories of waste:
- Failure of care delivery
- Failure of care coordination
- Overtreatment or low-value care
- Pricing failure
- Fraud and abuse
- Administrative complexity
Administrative complexity accounted for the largest amount of estimated annual wasteful spending at $265.6 billion. In a blog post published last week, CMS Administrator Seema Verma outlined the agency’s five-part “program integrity strategy.”
“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,” Verma wrote.
The five approaches to improve program integrity are as follows, according to Verma.
- Stopping bad actors: Several agencies are actively involved in identifying Medicare fraud and referring cases to law enforcement, including CMS, the Office of the Inspector General, the Department of Justice, and Unified Program Integrity Contractors.
- Preventing fraud: As opposed to Medicare's “pay and chase” model of combatting fraud in the past, CMS is developing approaches to prevent fraud, waste, abuse before claims are paid.
- Mitigating emerging programmatic risks: As Medicare shifts from the program's traditional fee-for-service payment model to value-based payment models, CMS is committed to developing safeguards to ensure the integrity of the new reimbursement processes.
- Reducing provider burden: While CMS steps up efforts to combat fraud, abuse, and waste, the agency is mindful that it should not create inappropriate time and cost burdens on healthcare providers.
- Deploying new technology: CMS is committed to deploying new technology to boost the efficiency of fraud, waste, and abuse reduction efforts. For example, CMS is hoping to upgrade the agency's Fraud Prevention System and case management systems.
Comments on the CMS Center for Program Integrity initiative can be submitted electronically via email at ProgramIntegrityRFI@cms.hhs.gov. Documents should be submitted in PDF format.
Editor’s note: This article originally appeared in HealthLeaders Media. To read the JAMA article on healthcare spending waste, click here. To read the Blog post from Seema Verma, click here.