Upton, Tiberi, Brady, Roskam, Hatch lead efforts to aid crackdown on Medicare fraud

Legislative leaders voiced concerns on Monday about fraudulent Medicare spending despite recent Centers for Medicare and Medicaid Services (CMS) efforts to crackdown on improper payments before they are made.

House Energy and Commerce Chairman Fred Upton (R-MI), House Ways and Means Health Subcommittee Chairman Pat Tiberi (R-OH), Ways and Means Chairman Kevin Brady (R-TX) and Ways and Means Oversight Subcommittee Chairman Peter Roskam (R-IL) were joined by Senate Finance Chairman Orrin Hatch (R-UT) in raising the concerns in a letter to CMS Administrator Andy Slavitt.

“The billions of dollars lost to Medicare fraud each year underscore the importance of stopping potentially fraudulent payments before they are made,” the lawmakers wrote. “Historically, CMS has paid claims and then, after the fact, investigated whether the claims were proper, a concept known as ‘pay and chase.’ Over the past several years, however, CMS has taken steps to stop payments before they go out the door.”

The efforts have included the Fraud Prevention System (FPS), which relies on predictive analytics to identify claims and providers that present high fraud risk. Improper payments remain a problem with Medicare’s fee-for-service program’s error rate, however, amounting to 12.1 percent.

“We remain supportive of CMS’ efforts to implement the FPS, but are concerned that the FPS continues to rely primarily on outdated ‘pay and chase’ activities rather than focusing on preventing potentially fraudulent dollars from going out in the first place,” the lawmakers wrote.

In order to understand the work of CMS to implement the FPS, the lawmakers asked for a breakdown of types of schemes impacting Medicare programs, the number of FPS leads that aided existing investigations, and to name development of adjustment factors to identify amounts saved or returned to the Medicare trust fund.