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Proposed PRIME Act Aims at “Preventing and Detecting” Medicare and Medicaid Fraud and Abuse

A proposed bipartisan bill, titled the Preventing and Reducing Improper Medicare and Medicaid Expenditures (PRIME) Act, is aimed at combatting waste, fraud, and abuse in Medicare and Medicaid spending. If passed, the PRIME Act would continue CMS’ efforts to move away from the “pay and chase” model of combatting improper payments towards the more aggressive “prevent and detect” model.

The PRIME Act would enact a range of reforms designed to proactively target improper payments, including fraud, within the Medicare and Medicaid programs. The reforms include, for example, engaging Medicare beneficiaries in identifying waste and fraud through a program called the Senior Medicare Patrol (SMP). The bill also seeks to administer harsher penalties for instances of Medicare or Medicaid fraud, as well as identify theft and the sale or distribution of Medicare and Medicaid beneficiary ID numbers.

In a press release addressing the bill, Rep. Peter Roskam (R Ill.) announced,

The problem of Medicare fraud is an urgent one–we cannot continue to allow these critical programs to be fleeced because of carelessness or criminals gaming the system. The program’s current pay-and-chase model pays out even suspicious Medicare claims… By combining 21st century technology and common sense solutions, the PRIME Act can help stop fraudsters in their tracks and make Medicare and Medicaid more financially stable for the long term.

Rep. Roskam’s announcement reinforces that the purpose of the PRIME Act is to aggressively detect potential improper payments before the payments are made to providers. Therefore, passage of the PRIME Act may increase pre-payment reviews. Although all audits, whether post-payment or prepayment, are burdensome for providers, prepayment reviews are often much more aggressive and could seriously affect a provider’s ability to continue to provide services. As a result, it is essential that all healthcare providers review their compliance strategies and policies. For more information on how passage of the PRIME Act may affect you or for more information on pre-payment review and strategies to utilize if on pre-payment review, please contact an experienced healthcare attorney at 248-544-0888 or wapc@wachler.com.