New Affordable Care Act Rules to Fight Healthcare Fraud

On Mon Jan 24, HHS announced new rules authorized by the Affordable Care Act which will help stop healthcare fraud. “Thanks to the new law, CMS now has additional resources to help detect fraud and stop criminals from getting into the system in the first place," CMS Administrator Donald Berwick, MD, said. “The Affordable Care Act’s new authorities allow us to develop sophisticated, new systems of monitoring and oversight to not only help us crack down on fraudulent activity scamming these programs, but also help us to prevent the loss of taxpayer dollars across the board for millions of American healthcare consumers.”

Specifically, the final rule:
 Creates a rigorous screening process for providers and suppliers enrolling Medicare, Medicaid, and CHIP to keep fraudulent providers out of those programs. Types of providers and suppliers that have been identified in the past as posing a higher risk of fraud (for example, durable medical equipment suppliers) will be subject to a more thorough screening process.
 Requires new enrollment process for Medicaid and CHIP providers. Under the Affordable Care Act, states will have to screen providers who order and refer to Medicaid beneficiaries to determine if they have a history of defrauding the government. Providers that have been kicked out of Medicare or another state’s Medicaid or CHIP will be barred from all Medicaid and CHIP programs.
 Temporarily stops enrollment of new providers and suppliers. Medicare and state agencies will be on the lookout for trends that may indicate healthcare fraud – including using advanced predictive modeling software, such as that used to detect credit-card fraud. If a trend is identified in a category of providers or geographic area, the program can temporarily stop enrollment as long as that will not impact access to care for patients.
 Temporarily stops payments to providers and suppliers in cases of suspected fraud. Under the new rules, if there has been a credible fraud allegation, payments can be suspended while an action or investigation is underway.

For more information:
 The full text of the press release issued on Mon Jan 24 is available at http://www.HHS.gov/news/press/2011pres/01/20110124a.html.
 A copy of the regulation is available in the Federal Register at www.OFR.gov/inspection.aspx or www.archives.gov/federal-register/news.html.
 A factsheet on the new rules can be found at www.HealthCare.gov/news/factsheets.


Dallas L Alford IV, CPA is a licensed Certified Public Accountant in the state of North Carolina and owner of Atlantic Financial Consulting, a consulting firm that provides comprehensive medical billing services, practice management consulting, coding audits, Medicare compliance, Medicare RAC support and other general medical practice consulting services.
To learn more about Atlantic Financial Consulting you may visit their website at http://atlanticfinancial.us or contact Dallas L Alford IV, CPA directly at 1 888-428-2555, Ext. 200.