Thousands lose Medicare billing rights during revalidation

CMS has removed health professionals with outdated and invalid enrollment records as it works to strengthen Medicare participation rules.

By Charles Fiegl amednews staff — Posted June 14, 2012

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Medicare has revoked or deactivated the billing privileges of more than 23,000 health professionals and equipment suppliers during the initial stages of a nationwide enrollment revalidation effort.

The Centers for Medicare & Medicaid Services has enrolled or revalidated more than 275,000 professionals since March 25, 2011, when the agency began using strengthened measures to rescreen 1.5 million participants. Medicare officials have targeted areas of the program, such as the durable medical equipment field, that are susceptible to fraud and removed invalid suppliers from the program, CMS Center for Program Integrity Director Peter Budetti, MD, said during a June 7 House Oversight and Government Reform subcommittee hearing.

Dr. Budetti did not have a breakdown of the types of health professionals and suppliers whose privileges have been ended. But CMS has used an automatic screening process to remove several physicians because they did not have state licenses or were not in federal enrollment databases, he said. The system also will alert the agency when doctors lose licenses to practice medicine, commit felonies or die — allowing CMS to prevent those physician billing numbers from being used improperly.

“This is all new,” Dr. Budetti told the Government Organization, Efficiency and Financial Management subcommittee. “Most of what was done in the past was done manually and substantially less efficient.”

Rep. Todd Platts (R, Pa.) questioned whether the initial figures mean that about 120,000 Medicare enrollees eventually could be removed as CMS completes the revalidation effort by March 2013. Dr. Budetti noted that the agency started revalidating high-risk professionals and eventually will revalidate all physicians, who are considered low-risk professionals.

CMS is using a “twin pillar” strategy for improving Medicare program integrity, Dr. Budetti said. One pillar includes the enhanced enrollment screening, while the other features predictive analytic technology to detect abnormal billing patterns.

“These pillars represent an integrated approach to program integrity — preventing fraud before payments are made, keeping bad providers and suppliers out of Medicare in the first place, and quickly removing wrongdoers from the program once they are detected,” he said.

Auditing concerns

Rep. James Lankford (R, Okla.) questioned government officials about the increased use of Medicare recovery audit contractors, whose scope recently has been expanded to Medicaid. The process used to examine past physician and hospital claims for overpayments has led to billions of dollars being recouped, but critics have decried some of the actions of what they term “bounty hunters.”

The RAC program began as a demonstration project, said Kathleen King, a Government Accountability Office director of health who focuses on Medicare. “There were some missteps by CMS in terms of issues explored and perhaps overaggressiveness.”

But CMS took concerns regarding the demonstration into account when it expanded the RAC program nationwide. The agency has placed limits on what billing situations contractors can explore, King said.

The monitoring of the audits in Medicare and Medicaid will continue. The GAO is examining overall CMS investigations of Medicaid claims. Investigators are measuring the effectiveness of the RAC process and efforts to redesign federal audit programs.

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