Premier Responds to RFI on CMS’ Waste, Fraud and Abuse Efforts

Premier submitted comments to CMS' request for information on strengthening fraud prevention efforts, as the agency considers potential future rulemaking under its Comprehensive Regulations to Uncover Suspicious Healthcare (CRUSH) initiative. The RFI seeks stakeholder input on ways CMS can better prevent, detect, and respond to fraud, waste and abuse, as well as program inefficiencies, across Medicare, Medicaid, CHIP, and the Health Insurance Marketplace.

In its comments, Premier recommends that CMS:

• Consider modifications to program integrity efforts, including:
  • Streamlining and coordinating reporting of suspected WFA within the federal government and Medicare Administrative Contractors;
  • Creating a public national dashboard of significant, anomalous, and highly unusual billing activity by providers;
  • Establishing an ACO-specific "hotline" for reporting suspected WFA;
  • Rewarding ACOs for successful detection of WFA;
  • Administering technical changes to remove claims held in escrow from ACO reconciliation;
  • Increasing transparency around suspected fraud;
  • Set clear criteria for immediately pausing payments to suspicious suppliers;
  • Create codes to monitor the results of wound care and skin substitute products;
• Take action to protect ACOs and providers who participate in downside-risk payment models from the harmful impact of WFA;
• Consider enhanced identify and ownership verification requirements to reduce fraudulent claims submissions by foreign suppliers;
• Consider the potential inadvertent consequences of shorter claim submission timeframes; and
• Leverage the private sector's investments in technology-enabled self-audits to improve compliance to payment policies in Medicare Advantage.