HHS announces new Affordable Care Act rules to fight health care fraud
4 February 2011
On Jan. 24, the Department of Health and Human Services (HHS) announced new rules, authorized by the Affordable Care Act, to help stop health care fraud, expand consumer protections, strengthen Medicare and protect taxpayer dollars. The final rule:
- Creates a rigorous screening process for providers and suppliers enrolling in Medicare, Medicaid and Children’s Health Insurance Program (CHIP) to keep fraudulent providers out of those programs. Types of providers and suppliers that have been identified in the past as posing a higher risk of fraud will be subject to a more thorough screening process.
- Requires a new enrollment process for Medicaid and CHIP providers. States will have to screen providers who order and refer to Medicaid beneficiaries to determine if they have a history of defrauding the government. Providers that have been kicked out of Medicare or another state’s Medicaid or CHIP will be barred from all Medicaid and CHIP programs.
- Temporarily stops enrollment of new providers and suppliers. Medicare and state agencies will look out for trends that may indicate health care fraud and will use advanced predictive modeling software, like the software used to detect credit card fraud. If a trend is identified in a category of providers or geographic area, the program can temporarily stop enrollment as long as it does not impact access to care for patients.
- Temporarily stops payments to providers and suppliers in cases of suspected fraud. If there has been a credible fraud allegation, payments can be suspended while an action or investigation is underway.