Once again, the Centers for Medicare and Medicaid Services (CMS) has alleged fraud and abuse in the system it oversees and announced a major clampdown on a specific set of programs until matters are investigated.

The latest development centers on the agency on Tuesday issuing a six-month, nationwide data-driven moratoria on new Medicare enrollment for hospices and home health agencies (HHAs).

“Today’s move continues the Trump Administration’s crackdown on fraud, waste, and abuse in the Medicare program by stopping improper billing and preventing bad actors from entering the system,” the agency said.

This follows a similar move earlier in the year when CMS issued a moratorium to prevent fraudulent Medicare billing by certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) companies.

Not Happening

With the administration on the prowl, the question is could the nursing home sector soon be coming under an even closer microscope than usual?

Not likely, said Brian Fuller, a managing director in ATI Advisory's Value-Based Care Design and Delivery Practice. “We haven't heard the same level of fraud, waste, and abuse concerns on the SNF side that we have on the home health and hospice side. Also, there's a lot tighter certificate of need regulations [in states] around SNFs than there are in home health and hospice,” he said.

There are also capital barriers that are a lot more significant in the SNF sector.

“It's a lot easier to have a fake shingle of a business when you can't go and see the real estate. It's much more difficult to do that on the SNF side,” Fuller said.

Feds on the Lookout

During the six-month moratoria for hospice and HHAs, CMS said it will intensify targeted investigations, deploy advanced data analytics, and accelerate the removal of hospice and HHA providers from the Medicare program that are suspected of committing fraud.

In addition, the moratoria will apply to all applications for initial Medicare enrollment and certain changes in majority ownership, which are frequently used to obscure control by bad actors, CMS alleged.

The moratoria will not impact current enrollments, and existing providers can continue to deliver services to Medicare beneficiaries.

Other Steps

Additional CMS work in the hospice and HHA areas has included:

• Revoking or deactivating hundreds of hospices and HHAs engaged in improper or fraudulent activity;

• Conducting nationwide hospice site visits to verify operations and identify suspicious activity;

• Heightened oversight of newly enrolled Medicare hospice providers in states with elevated fraud risk, including Arizona, California, Georgia, Ohio, Nevada, and Texas;

• Launching a new, publicly available hospice scoring system to increase transparency and identify providers with troubling patterns of utilization, quality, or compliance;

• Implementing enhanced enrollment screening measures for high-risk HHAs, including site verification of reported practice locations and fingerprinting-based background checks; and

• Expanding a demonstration project that allows pre- and post-claim review of HHA claims in Florida, Illinois, Oklahoma, Ohio, North Carolina, and Texas to stop improper payments before they occur.

Additional information on the Hospice and Home Health Agency moratoria can be found via the Federal Register at: https://www.federalregister.gov/

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