Senator Chuck Grassley recently introduced new legislation to fight health care fraud, waste, and abuse. The bill, titled The Strengthening Program Integrity and Accountability in Health Care Act (S 2774) includes many of the fraud prevention provisions from the comprehensive health care reform bills, which are now being reconsidered. As the ranking member of the Senate Finance Committee, Sen. Grassley had a hand in developing many of the provisions included in the health care reform bill, and subsequently this newly introduced anti-fraud bill. The proposed bill enhances efforts by federal health care programs and federal enforcement agencies to curtail fraudulent activities committed by current and new providers.
Several of the bill’s provisions focus on fraudulent or potentially fraudulent claims submitted for payment by providers and suppliers. Providers should be aware of the following key proposed measures:
- Reducing the submission period for Medicare claims to no more than 12 months;
- Requiring providers to report and return overpayments within 60 days after either the date the overpayment was identified or the due date of the corresponding cost report;
- Expanding of the Recovery Audit Contractors Program to Medicaid and Medicare Parts C and D;
- Consolidating the repository of claims for all parts of Medicare, Medicaid, CHIP, Veterans Affair, Department of Defense, Social Security, and Indian Health Services into a single, Integrated Data Repository; and
- Granting DHHS OIG and Department of Justice access to Medicare and Medicaid claims for the purpose of carrying out law enforcement activities.
Considering the increased attention for claims reviews through integrated data systems, it is crucial for providers to know and analyze their data just as well as government enforcers would. Providers should conduct a prepayment review of all claims before submission to identify errors, and subsequently before the issuance of a denial or overpayment. Further, it is advised to conduct a mock review of paid claims to mimic reviews conducted by government contractors. Mock reviews are often conducted by external entities with expertise and knowledge of high risk billing issues. Risk areas under review by the Recovery Audit Contractors often serve as the starting point. Mock reviews are a beneficial and informative way to know and manage billing risks.
If overpayments are identified through claims reviews and data mining efforts, they must be reported and returned to the appropriate payer. Therefore, it is essential to have a process in place to report and return such overpayments on a timely basis. This process should be documented in a written policy and should be reviewed and updated on a regular basis.
Currently, the Senate Finance Committee is reviewing the proposed bill, after which it is likely to move to the Senate for full vote. Therefore, providers have sufficient time to start conducting their own claims reviews before enhanced government enforcement begins. Undoubtedly, both sides of the health care reform debate agree that fraud, waste, and abuse must be addressed and ultimately reduced. Therefore, it is not a matter of if such measures will pass but when.
Posted by: Jillian Bower, Associate at Strategic Management
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