In the wake of MU fraud, we all need CMS' answers to legislator questions
It's not surprising that less than a month after the first indictment of a former hospital executive for false attestation to Meaningful Use that a House Committee has asked the Centers for Medicare & Medicaid Services and the U.S. Department of Health & Human Services Office of Inspector General to justify how well they're policing the payments to providers.
The committee asked CMS Administrator Marilyn Tavenner to answer a variety of questions, including ones about the adequacy of screening providers before incentive and claims payments are made; the agency's use of predictive modeling to ferret out problematic providers; how much the zone program integrity contractors (ZPICs) have accomplished; how CMS is assured that it's notified about "credible allegations of fraud" by providers; and how many revocations CMS has made in the last 10 years. Clearly the focus is on identifying problem providers before or while they're being paid, not after.
The committee's questions to OIG are along the same vein: What recommendations has the OIG made to CMS relating to screening providers before they're paid? What actions is OIG taking to examine how CMS can improve screening. What other databases could CMS use to screen?
OIG isn't going to fare too badly. It's already on record for chastising CMS for not verifying the accuracy of attestation information and for dropping the ball on addressing EHR vulnerabilities. OIG has already told CMS to step up prepayment review, a recommendation that CMS disagreed with. And OIG is stepping up to the plate itself, for the first time intending to audit providers receiving Meaningful Use incentive payments.
CMS' defense will be harder, although the committee may be being a bit harsh on the agency. After all, it was Congress that created the Meaningful Use program and required CMS to pay out billions to spur providers to adopt EHRs very quickly. If Congress had wanted CMS to be more conservative in verifying attestations pre-payment, it could have emphasized that in the legislation. Indeed, CMS' argument against more pre-payment review is that it would create a "huge new burden" that would impede EHR adoption.
Moreover, this "pay-and-chase" set up regarding the Meaningful Use payments is similar to the pay-and-chase system still being predominantly used to pay claims. CMS was supposed to pay providers by a certain deadline, so it did.
However, Congress has recently indicated that it prefers a to move away from pay and chase, a strategy CMS has embraced, enacting Affordable Care Act regulations that require background checks on some providers before enrollment and other initiatives.
So if one reads between the lines (or is very familiar with recent laws and regulations), what the committee is really getting at is whether CMS is adequately using the new tools it has to stop improper payments before they go out the door.
For instance, the term "credible allegations of fraud" is a new buzz phrase from the Affordable Care Act that expands the agency's authority to suspend payments being made to providers. The Small Business Jobs Act of 2010 required CMS to develop a system to use predictable modeling to detect and prevent fraud, which CMS did.
The committee questions are reasonable. How is CMS measuring up? Is it checking exclusion and provider death databases before making payments? Does the predictable modeling computer system work? How are those Meaningful Use audits going?
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Prepayment review of Meaningful Use incentives is ok by me