Fighting Medicaid Fraud, Waste, and Abuse Through Education

By Ted Doolittle, CMS Deputy Director, Center for Program Integrity

The Centers for Medicare & Medicaid Services (CMS) wants everyone to join in the fight against fraud, waste, and abuse as part of our comprehensive strategy to protect federal health care programs and taxpayer dollars.  We are now making it easier than ever before for health care providers, managed care plans, and individuals and families with Medicaid benefits to use the education and training materials on the new Medicaid Program Integrity website.

Resources available on the website include videos, fact sheets, and checklists, made specifically for providers and beneficiaries.  These tools are national in scope, but some information can be personalized by your State of residence (or where you live) upon request.  One of the key resources is a brochure on how people with Medicaid can protect themselves and the Medicaid program from fraud. You can also email MedicaidProviderEducation@cms.hhs.gov for the state contact number for reporting fraud.

State program integrity professionals and counselors will also find valuable education and training materials on the site – all available at no cost.  We have developed toolkits to address hot issues and frequently asked questions about Medicaid program integrity, including beneficiary protections and compliance resources for dental professionals and managed care organizations.  Take a moment to learn more about the CMS Medicaid Program Integrity education and training materials available by clicking on this link, that will take you to the CMS.gov website.

Click here to join our listserv to receive timely notices of new material as it becomes available. Listserv members are also notified when new training, education, or speaking events are scheduled.

We value your feedback, recommendations, questions, and requests and encourage you to e-mail the Education Medicaid Integrity Contractor at medicaidprovidereducation@cms.hhs.gov for further information.

Thank you for being a partner in Medicaid program integrity!

And for more information on CMS’s efforts to protect consumers in the Health Insurance Marketplace, please visit: http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-Sheets/2013-Fact-Sheets-Items/2013-09-18.html

Premium and Prescription Savings are Good News for People with Medicare

By Jonathan Blum, CMS Principal Deputy Administrator

The Centers for Medicare & Medicaid Services (CMS) has announced the 2014 Part B premiums in original Medicare and most seniors and people with disabilities will not increase next year, staying at $104.90 a month for Part B premiums.

For the third year in a row Medicare premium costs are meeting or beating expectations.  Monthly Medicare premiums in 2013 are lower than the $109.10 they were projected to be.   The year before, premium costs came in six dollars lower than the experts predicted.  The last five years have been among the slowest periods of average Part B premium growth in the program’s history.

Lower original Medicare costs are just one of the positive changes we’ve seen in Medicare since the Affordable Care Act was signed into law.

Since 2010, more than 7.1 million seniors and people with disabilities who reached the donut hole have saved $8.3 billion on their prescription drugs, an average of $1,167 per person.     In 2014, people with Medicare who have entered the donut hole will receive discounts and coverage of about 53 percent on the cost of brand name drugs and 28 percent coverage for the cost of generic drugs. Prescription drug savings and Medicare coverage will gradually increase until 2020, when the donut hole will be closed.

Medicare Advantage plan benefits and prices continue to improve thanks to a new Affordable Care Act star-rating system that pays plans based on quality.  Since passage of the Affordable Care Act, average Medicare Advantage premiums are down by 9.8 percent.  More beneficiaries are able to access and choose high quality plans – more than half are in four or five-star plans for 2014, up from 37 percent this year.

Other Affordable Care Act changes that pay hospitals and doctors based on the quality of care they deliver for patients—like reducing hospital readmissions, which have started to drop after being stuck for the past five years—are beginning to have an effect.  Programs like Hospital Value-Based Purchasing and Accountable Care Organizations are making sure that improved quality of care for patients is at the center of efforts to reduce cost growth.  Over the last four years, the stronger anti-fraud measures instituted by the Affordable Care Act has enabled the Obama administration to recover over $14.9 billion for taxpayers.

And health care spending has grown more slowly in the past few years than it has since the 1960s.  We’re working hard to make sure these gains continue.  Meanwhile, lower costs and better care is great news for the Trust Funds, great news for taxpayers, and really great news for people with Medicare.

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Moving Forward on Arkansas’ Innovative Plan to Provide Health Coverage to 200,000 Arkansans

By Cindy Mann CMS Deputy Administrator and Director, Center for Medicaid and CHIP Services

Today, the Centers for Medicare & Medicaid Services announced the approval of the Arkansas Medicaid 1115 Demonstration to expand Medicaid coverage to over 200,000 people that do not have access to health coverage.  This demonstration is part of the state’s larger initiative to create affordable, quality coverage options for all its residents. This coverage is possible thanks to the Affordable Care Act.

Over the last few months, CMS has worked closely with Arkansas on the Arkansas Health Care Independence Program, or as they call it in Arkansas, the Private Option and has benefited from public comments from a diverse group of stakeholders. Under the Private Option demonstration, the state will use premium assistance to provide adults who make $15,280 or less with coverage provided by Qualified Health Plans operating in the Health Insurance Marketplace. As a result, most of the newly eligible adults in Medicaid will receive almost all of their Medicaid benefits and cost-sharing coverage through the same plans that are serving Arkansans who enroll through the federally facilitated Marketplace. Under this and all premium assistance approaches, individuals in the demonstration retain all the rights, responsibilities, and protections as other Medicaid beneficiaries, including cost-sharing protections.

Outreach, the application process, and plan choice will be the same regardless of whether an Arkansas resident is enrolled in Medicaid or has a premium tax credit through the Marketplace. Arkansas is leading the state’s outreach effort for the Marketplace.  It is training “Health Insurance Guides” to help individuals in all 75 counties understand their options.  It has been running advertising on 28 television stations, 24 regional radio stations, 118 community radio stations, and in 120 community newspapers.  In addition, ads have been placed on 227 billboards, 100 gas pumps, two Central Arkansas Transit buses, and direct mail will be sent to 254,000 households and 172,000 small businesses.  The marketing tag line of “Get In” has switched to “Get Informed” and will be shift to “Get Enrolled” beginning October 1, 2013. Open enrollment for the new Medicaid demonstration as well as the Marketplace will begin on October 1, 2013 with eligibility effective January 1, 2014.

The Administration remains committed to working with states on the flexibility and resources they need to build new systems for health coverage.  Premium assistance is one option, and we will continue to work with states on solutions that work best to meet shared goals.  We encourage states to come to us with their delivery system ideas, and look forward to continuing to work with states on these and other innovative approaches to provide affordable coverage to all Americans.

Encouraging news about enrollment in Medicaid and CHIP

By Cindy Mann, Deputy Administrator and Director, Center for Medicaid & CHIP Services, Center for Medicare & Medicaid Services (CMS)

When it comes to getting children the health coverage they need, our nation is moving in the right direction.  According to a new analysis by the Urban Institute, the participation rate in Medicaid and the Children’s Health Insurance Program (CHIP) has increased to 87.2 percent in 2011, up 5.5 percentage points from 81.7 percent in 2008. Over that same time period, the number of eligible uninsured children has declined from 4.9 million to 4.0 million.  At CMS, we are greatly encouraged by this progress, because we know a bump in participation means that more children are getting access to the comprehensive health benefits – including preventive services – that all children need.

In addition to the work states have done over the past decade or more to simplify and streamline enrollment procedures, outreach efforts that include providing application assistance directly to families have played a key role in improving enrollment.  Secretary of Health and Human Services, Kathleen Sebelius helped galvanize these efforts in 2010, when she launched the Connecting Kids to Coverage Challenge, calling upon leaders at all levels of government, community-based organizations, health centers, school districts, faith-based groups, Indian tribes and others to find and enroll all uninsured children eligible for Medicaid and CHIP eligible children.  We are proud that, working together, our national Connecting Kids to Coverage Campaign, our outreach and enrollment grantees and many other partners have helped to achieve the progress described in the Urban Institute report.

But, there is still more to be done.  Too many uninsured children who could be eligible for Medicaid and CHIP today remain uninsured.  As the Connecting Kids to Coverage Campaign continues to reach out to families across the country, we know that new opportunities to boost enrollment are just around the corner.  Beginning October 1, as a result of the Affordable Care Act, many more parents will be eligible for Medicaid or other coverage available through the Health Insurance Marketplace.  And we know that when eligible parents enroll, they are also likely to enroll their children and take advantage of the preventive services that help them stay healthy.

To find the children’s Medicaid/CHIP participation rate in your state check out this map: http://www.insurekidsnow.gov/professionals/reports/index.html

To find out about health insurance opportunities for the whole family:

https://www.healthcare.gov/

For recent children’s health coverage outreach materials and ideas for how best to use them:

http://www.insurekidsnow.gov/professionals/back_to_school.html

Watch the Insure Kids Now television public service announcement here: http://www.insurekidsnow.gov/professionals/outreach/strategies/tv_and_radio_psas.html

Find out more about the grants we’ve awarded to groups across the country: http://www.insurekidsnow.gov/professionals/index.html

 

A guide for new and first-time physicians participating in federal healthcare programs

By Shantanu Agrawal, MD

With a new class of medical residents beginning their training, and residents and Fellows graduating from their programs every July, it’s important that our critical partners in the delivery of healthcare have the tools they need to understand federal program requirements.  At the Centers for Medicare & Medicaid Services (CMS) we have a comprehensive strategy to reduce fraud, waste and abuse that is designed to target risk – that means as we make it harder for bad actors to enroll or bill in our systems, we are always evaluating how to make it easier for legitimate physicians and other providers to participate in Medicare and care for beneficiaries.

CMS demonstrates this commitment with several initiatives:

  • Providers enrolling in Medicare for the first time now have a much easier experience enrolling than in years past. Since 2012, paper is no longer required to complete an application.  Everything can be submitted online, using web-based “PECOS” (the Provider Enrollment, Chain and Ownership System – the official record of every provider in Medicare). That includes required signatures and attachments, such as medical licensure. If an application fee is required – typically owed by organizations – it can also be paid online. The conveniences of the web-based PECOS system allow for faster application processing times over paper-based applications.
  • We recently launched two free mobile applications for Apple iOS and Android devices to help various stakeholders comply with the new requirements of the Open Payments program (commonly known as the Physician Payments Sunshine Act). This program tracks financial relationships between covered physicians and the health care industry – such as pharmaceutical and medical device companies – and will make the data available to the public annually on a website currently being designed. Physicians are not required to report any data, but the mobile applications will help them to track financial relationships and assess reported data for accuracy.
  • CMS is also modernizing how we communicate with physicians. We are now using Facebook / Facebook4 and Twitter / Twitter10 to keep tech-savvy providers up-to-date on the latest CMS news and progress being made.  Use these resources to engage and share your comments on our program efforts via Email and Google.
  • At CMS we also know the risks and challenges that many new physicians face in today’s healthcare landscape. We are dedicated to helping new physicians stay on track with important updates in our Medicare and Medicaid operations. That’s why the Center for Program Integrity is making it easier for physicians to resolve issues of identity theft. We’re providing information on how to protect your medical identity, numerous educational toolkits and Continuing Medical Education (CME) on CMS program integrity activities.

New and practicing physicians should note that as CMS shifts its fraud-fighting strategy to become more proactive, people committing fraud are doing the same. In our long-running patient education programs, we have provided ways patients and their families can spot and prevent scams. And we are developing more fraud-focused materials for health care providers and suppliers.

New physicians are emerging as a new vulnerability because of their inexperience with federal programs, financial obligations resulting from medical school, and aggressive scammers skillfully crafting schemes that appear to be legitimate.

New doctors should be aware of job offers that appear “too good to be true.” As with any other professional offer received or found — in print, on the internet, or other reputable or often-used resources – please be wary of offers that pay large sums of money in exchange for reviewing medical records written by others. Most often these include night and weekend work offers for your professional services to assist home health and durable medical equipment operations, usually off-site.

For Medicare fraud scams, they will require that you enroll or be enrolled in Medicare or PECOS. Never accept money or gifts for work you did not perform. Scammers that are offering cash for your participation in fraud are quick to disappear and have no issue with leaving you out to dry. Convictions for certain health care fraud violations will result in exclusion from federal healthcare programs – and potentially preventing your participation in certain State Medicaid programs and private health plans. Remember, the penalties are much larger than any short-term benefit.

To help new physicians develop defenses against these scams, CMS urges you to:

And most importantly, all doctors and their patients should report fraud as soon as it is suspected to the HHS Office of Inspector General. Tips can be reported either online or by phone at 1-800-HHS-TIPS. It’s never too late to report information, and by doing so you will be joining the fight to protect federal healthcare programs for future generations.

Shantanu Agrawal, M.D., is the Medical Director for the Center for Program Integrity at the Centers for Medicare & Medicaid Services.

CMS Moves Toward Greater Transparency

Historically, information on charges and costs for health care services has not been available to the public. Receiving a bill at the end of a treatment was generally the only way a person could find out the cost of health care services. CMS is working to usher in a new era of transparency and is very pleased to announce its next steps to create a more transparent health care system.

Today, CMS is releasing a request for public comment regarding physician-specific payment information. On May 31, 2013, a Florida federal district court lifted a 1979 permanent injunction that prohibited CMS from disclosing annual Medicare reimbursement payments to individual physicians.  In light of this recent legal development and our ongoing commitment to greater transparency in the health care system, CMS seeks public input on the best way to move forward. We are seeking input in three specific areas:

  1. how to properly weigh the balance between any potential privacy interest a provider has and the public interest in disclosure of Medicare payment information;
  2. what specific policies CMS should consider with respect to disclosure of individual physician payment data, especially with to prevent the release of any health information on any Medicare beneficiary; and
  3. what form any potential data release might take (e.g., line item claim details, aggregated data at the individual physician level).

In addition to releasing this request for public comment, CMS is also announcing four new qualified entities (QE). Created as part of the Affordable Care Act, the Medicare Data Sharing for Performance Measurement Program allows organizations to combine Medicare claims data from CMS with claims data from other payers to evaluate the performance of providers, services, and suppliers. The four additional QEs named today are Minnesota Community Measurement (MNCM), Wisconsin Health Information Organization (WHIO), Minnesota Department of Health (MDH), and the Center for Improving Value in Health Care (CIVHC). They will join the seven existing QEs in helping CMS improve quality, reduce costs, provide important information to beneficiaries to help them make health care decisions, and increase transparency.

Today’s announcements are only the latest of several efforts that demonstrate this Administration’s and this agency’s commitment to making health care more transparent.  In May 2013, CMS released information on the average charges for the 100 most common inpatient services at more than 3,000 hospitals nationwide, followed in June with the release of average charges for 30 selected outpatient procedures. CMS has also prioritized the provision of Medicare data to Accountable Care Organizations partnering with Medicare to improve care.

It is important to note that none of these efforts will result in the public disclosure of any information that could directly or indirectly reveal patient-identifiable information.  CMS is committed to appropriately the privacy of its beneficiaries.

CMS recognizes the potential for transforming the health care system that our data provides. By making our charge information public, we can help promote initiatives that can reduce costs and improve quality. This is only the latest step CMS is taking to increase transparency, but it won’t be the last.

Medicaid at Forty-eight

Cindy Mann, Deputy Administrator of the Centers for Medicare & Medicaid services and Director of the Centers for Medicaid and CHIP Services

Since 1965, Medicaid and Medicare have provided comprehensive and affordable health insurance to millions of Americans. Now, 48 years later, Medicaid continues to make strides towards connecting more eligible individuals with coverage and providing quality, affordable care. Now, as of 2013, 56.9 million people are covered by Medicaid, including 27.8 million children, 13.1 million adults and 15 million aged or blind/disabled persons.

 Key Medicaid Coverage Milestones

Children & Babies

                   •    Medicaid plays a key role in child and maternal health, financing approximately 40 percent of all births in the United States.

                   •    According to the Centers for Disease Control and Prevention, the rate of uninsured children dropped from 8.9 percent in 2000 to 6.6 percent in 2012, with millions gaining coverage – mainly through Medicaid and CHIP.

Elderly & Disabled           

•     Medicaid provides health coverage to more than 4.6 million low-income seniors, nearly all of whom are also enrolled in Medicare. Medicaid also provides coverage to 3.7 million people with disabilities who are enrolled in Medicare.

·                   •    Medicaid provides health coverage to over 8.8 million non-elderly individuals with disabilities, including people who are working or who want to work.

 Medicaid Moving Forward

As Medicaid turns 48, the program is evolving and there have been many important improvements to the program to help states across the country prepare for changes under the Affordable Care Act.  The Centers for Medicare & Medicaid Services (CMS) and states are partnering to implement streamlined eligibility rules and systems that will help ensure that eligible beneficiaries can enroll in the program that is right for them, whether Medicaid or coverage through the Health Insurance Marketplace.  And CMS continues to partner with states to improve the way care is delivered to help ensure Medicaid beneficiaries receive high quality health care services.  For example, over the last year, Medicaid has:

                 –  Issued guidance on a new state option for implementing integrated care models without a waiver that help states coordinate care in a fee for service delivery system;

-                                 –   Launched a new website to help states better implement long-term services and supports delivered through a managed care system;

-                                 –  Helped states and consumers to design new person-centered care programs and demonstrations and enhance current programs to improve coordination of care for Medicare-Medicaid enrollees;

-                                 –  Released major new funding opportunities for states and health providers and plans to design and test new delivery system models focused on multi-payer initiatives, new primary care initiatives, and improvements in birth outcomes; and

-                                -  Approved various initiatives to provide additional federal financial support to promote cost effective integrated care for individuals with chronic conditions and to help states improve access to home and community based long term services and supports. 

Medicaid also stands ready to serve more adults as states across the country take up the Medicaid coverage expansion as a result of the Affordable Care Act.  In 2014, states that expand Medicaid coverage to all adults with incomes at or below 133 percent of the federal poverty level can take advantage of 100 percent federal funding for the first three years and never less than 90 percent thereafter, thus extending Medicaid coverage to individuals who have historically been left out of the health insurance market.

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