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CMS Publishes Proposed Rule Implementing Affordable Care Act Provisions

The Centers for Medicare and Medicaid Services (CMS) published a proposed rule implementing provisions of the Patient Protection and Affordable Care Act (PPACA) that help tackle Medicare and Medicaid fraud.  According to Peter Budetti, the Director of the new anti-fraud office at CMS, the proposed rules will provide federal authorities the power to identify fraud and reduce improper payments by an estimated $55 billion.

According to CMS, the proposed rule is essential to the implementation of healthcare reform since the expansion of healthcare coverage relies upon saving money on fraud and abuse in the healthcare systems.  Specifically, the rules will provide increased scrutiny to $900 billion in annual spending in federal Medicare, and the state-federal Medicaid and Children’s Health Insurance Program (CHIP), but it is unknown how much money the proposed rules will actually save.

Increased scrutiny over Medicare and Medicaid Programs will include the following measures:

– As soon as there has been a “credible allegation” of fraud that warrants further investigation, payments to that provider will be suspended.

– Medicaid programs will be required to not use providers that have been kicked out of Medicare or another state’s Medicaid or CHIP program.

– More providers’ offices and firms will be visited to ensure their legitimacy.

– Providers will be rated on their risk for engaging in fraud.  Providers with a high-risk of fraud and new home-health agencies and suppliers will undergo fingerprinting and criminal background checks.

There is a 60 day comment period for the proposed rule and a final rule is expected to be published by the end of 2010.

For more information on healthcare reform, this proposed rule and its implications for health care providers, or compliance measures please contact a Wachler & Associates attorney at 248-544-0888. 

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