Crackdown on fraud means changes for providers

The government is continuing its commitment to stopping fraud by instituting more advanced screening and prevention techniques as part of the Patient Protection and Affordable Care Act. The focus of the effort, which is backed by $350 million, is on prevention rather than recovery, and that means some changes for providers.

Providers wishing to participate in Medicare, Medicaid, and Children's Health Insurance Program will endure more detailed screening, and any enrollees who are identified as high risk for fraud will be more closely scrutinized. A new enrollment process requires states to screen enrollees for past fraud, and any identified offenders will be ineligible to participate.

New software will allow Medicare and states to identify trends among providers and suppliers that could be evidence of fraudulent activity. If it's determined that a particular area is high-risk, the government will put a temporary halt on enrollment, provided such action doesn't affect patient care.

In addition, the government can temporarily suspend payment to any provider thought to be engaging in fraudulent activity, and once there is a legitimate allegation, suspension of payment can continue throughout the investigation.

The initiative also includes increased staffing for legal enforcement, sharing of claims data among healthcare-related government programs, required documentation for certain referrals, mandatory anti-fraud compliance plans for providers and suppliers, broader authority for Recovery Audit Contractors to correct over- and underpayments, greater penalties for those who engage in fraud, and improved prevention and investigation tools to deal with private insurance fraud.