CMS Proposes New Regulatory Measures to Combat Medicare Fraud
The Centers for Medicare & Medicaid Services (CMS) is enhancing its strategy to address healthcare fraud, waste, and abuse within the Medicare program through new regulatory measures. These efforts are detailed in the draft Calendar Year 2027 Home Health Prospective Payment System Proposed Rule (CMS-1844-P), aiming to reinforce authority over providers and potentially save $82 million annually in taxpayer funds.
The proposed regulation seeks to revise Medicare reimbursement and policy frameworks for home health agencies, proposing a 2.4% payment increase, or $420 million. These provider enrollment guidelines would encompass all provider types and suppliers participating in the federal healthcare program.
"These proposals would equip CMS with enhanced mechanisms to safeguard Medicare beneficiaries," CMS Administrator Mehmet Oz, M.D., stated, emphasizing efforts to exclude fraudulent providers and recover improper payments. Critical elements of the rule allow CMS to expand the criteria for taking action against providers, such as terminating Medicare participation in regions with "excessive" provider density, an identified risk factor for fraudulent activities.
Further provisions enable CMS to reject Medicare enrollment for providers with specific misdemeanor convictions within the last decade. Additionally, enrollment could be denied or revoked for ownership discrepancies or disciplinary issues in other federal healthcare programs, focusing particularly on home health agencies and durable medical equipment suppliers failing to perform necessary re-enrollment after ownership changes.
CMS also proposes making enrollment revocation effective retroactively, facilitating the reclamation of improper payments more efficiently. This is part of ongoing efforts to analyze and manage fraud risks within federal healthcare programs, underscoring a commitment to regulatory compliance and financial stewardship.
The proposal includes updates for payment structures, considering the Patient-Driven Groupings Model (PDGM) and a temporary payment adjustment aimed at recapturing overpayments from 2020 to 2025. CMS is also exploring the inclusion of community-based palliative care as part of the Medicare home health benefit to ensure a comprehensive care approach.
The National Alliance for Care at Home commented that the proposed rate increase does not fully address the costs of quality care. Jennifer Sheets, CEO of the Alliance, expressed commitment to collaborating with CMS to ensure policies that enhance patient access and sustain the Medicare home health benefit. Overall, the proposed CMS changes aim to refine Medicare provider participation, ensuring program integrity and a robust risk management approach.