Stop­ping power

CMS won’t im­pose mora­to­rium, de­spite urg­ing

Modern Healthcare - - The Week In Healthcare - Joe Carl­son

Un­der new reg­u­la­tions, the CMS has the au­thor­ity to tem­po­rar­ily stop providers from en­rolling in Medi­care when the risk of fraud is high. The agency so far has not used the power, even now that its watch­dog is rec­om­mend­ing it, be­cause of the bur­den of ex­plain­ing the action.

HHS’ in­spec­tor gen­eral’s of­fice last week urged the CMS to im­pose a mora­to­rium on new Medi­care en­roll­ments of in­de­pen­dent di­ag­nos­tic test­ing fa­cil­i­ties in Los An­ge­les after a city­wide in­spec­tion found more than one-third of the 132 fa­cil­i­ties were not open dur­ing the day or not op­er­at­ing from listed ad­dresses.

Reg­u­la­tions un­veiled in February un­der the Pa­tient Pro­tec­tion and Af­ford­able Care Act al­low the CMS to im­pose mora­to­ri­ums in ge­o­graphic ar­eas or in spe­cific cat­e­gories of providers that are deemed at high risk of fraud.

The in­spec­tor gen­eral’s re­port noted that such in­de­pen­dent test­ing fa­cil­i­ties have a his­tory of fraud, in­clud­ing a 1997 au­dit that found 20% of them were not lo­cated at the ad­dresses pro­vided to the CMS. In­de­pen­dent di­ag­nos­tic test­ing fa­cil­i­ties are a type of free­stand­ing cen­ter al­lowed to per­form tests such as X-rays, MRIs, ul­tra­sounds and sleep stud­ies out­side of tra­di­tional hos­pi­tals and physi­cians’ of­fices.

Although the CMS did agree with a rec­om­men­da­tion that it pe­ri­od­i­cally make unan­nounced site vis­its to the LA fa­cil­i­ties, agency of­fi­cials de­clined the in­spec­tor gen­eral’s sug­ges­tion to im­pose a mora­to­rium on new en­roll­ments.

CMS spokesman Brian Cook con­firmed that the agency has not used the power.

In a re­sponse to the re­port, CMS Ad­min­is­tra- tor Dr. Don­ald Ber­wick wrote that the agency “is con­sid­er­ing ap­pro­pri­ate cri­te­ria” for mora­to­ri­ums in LA and else­where, not­ing that do­ing so re­quires pub­li­ca­tion of a de­tailed ra­tio­nale in the Fed­eral Regis­ter. He added that the CMS would be will­ing to work with the in­spec­tor gen­eral’s of­fice to develop the nec­es­sary data.

A par­al­lel in­ves­ti­ga­tion in Mi­ami found that nearly a third of the 92 fa­cil­i­ties there broke the same rules. Yet when the CMS moved to boot three non­com­pli­ant cen­ters from par­tic­i­pa­tion, it took about 17 weeks to com­plete the pa­per­work—dur­ing which time Medi­care ap­proved an­other $146,000 in claims for the three.

In­ves­ti­ga­tors vis­ited each fa­cil­ity in the two cities last year. They turned up nu­mer­ous in­stances of signs say­ing the lo­ca­tions were ac­tu­ally dif­fer­ent busi­nesses or fa­cil­i­ties hav­ing no sign at all. Eleven of the Mi­ami and LA ad­dresses were for pri­vate res­i­dences, and seven fa­cil­i­ties listed nonex­is­tent street ad­dresses.

The 73 non­com­pli­ant fa­cil­i­ties be­tween the two cities billed Medi­care for a to­tal of $8.8 mil­lion in 2010, in­clud­ing $4.1 mil­lion sent in after the in­spec­tion dates.

Newspapers in English

Newspapers from USA

© PressReader. All rights reserved.