The Future of Medicare Program Integrity

Earlier this month, President Trump announced an Executive Order charging CMS to propose annual changes to combat waste, fraud, and abuse in the Medicare program. That’s why I’m proud to announce our vision to modernize our program integrity methods to better protect taxpayers from fraud, waste and abuse in Medicare. Every dollar spent on Medicare comes from American taxpayers and must not be misused.

CMS defines program integrity very simply: “pay it right.” Program integrity must focus on paying the right amount, to legitimate providers, for covered, reasonable and necessary services provided to eligible beneficiaries while taking aggressive actions to eliminate fraud, waste and abuse. Our health care programs are quickly evolving; therefore our program integrity strategy must keep pace to address emerging challenges.

Government watchdogs routinely identify concerns about waste and abuse within our programs. The Government Accountability Office (GAO) has designated Medicare as a High Risk program since 1990 because of its size, complexity and susceptibility to improper payments. In 2018, improper payments accounted for 5% of the total $616.8 billion of Medicare’s net costs. While CMS regularly implements GAO recommendations, sometimes we lack the tools or capabilities to integrate worthy suggestions. The Medicare Fee-For-Service (FFS) program is limited by statute as to what methods can be used to prevent fraud, waste, and abuse. For example, last year’s President’s budget contained a legislative proposal to expand review of high risk areas in FFS. Under current statute, review is limited to durable medical equipment like wheelchairs. In contrast, other programs like Medicaid, Medicare Advantage, Medicare Prescription Drug Plans (PDPs), Tricare, Marketplace plans, and private insurers all have broad authority to review procedures for medical necessity and appropriateness. GAO has also recommended that Congress expand prior authorization in FFS.

Read full – https://www.cms.gov/blog/future-medicare-program-integrity

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