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CMS Makes Some Program Integrity Changes; Stark Revisions May Be Around the Corner

CMS is making some changes to lessen provider burden and frustration in the program-integrity realm without putting Medicare beneficiaries or dollars at risk, a top official said. That includes reducing the number of providers and suppliers thrown out of Medicare for technical reasons and revising the Stark regulations to promote coordinated care. CMS also is developing web-based documentation checklists that are more “user friendly.”

But striking the right program-integrity balance “always feels like dancing on the head of a pin,” said Kimberly Brandt, CMS’s principal deputy administrator for operations, at the Health Care Compliance Association’s Compliance Institute in Boston April 8.

The drop in Medicare revocations and deactivations, which strip providers and suppliers of their billing privileges, is dramatic (see box below). “We have increased compliance initiatives to reduce revocations,” Brandt said. For example, if a provider is no longer at the practice location in the Provider Enrollment, Chain and Ownership System (PECOS) but there isn’t a history of noncompliance, the CMS Provider Enrollment Operations Group may contact the provider to update its enrollment information. “Additionally, history-of-noncompliance checks are completed in relation to abuse-of-billing issues,” a CMS spokesperson says. “A holistic review of the provider/supplier is undertaken in order to determine whether the behavior in question is likely an administrative error or truly represents fraudulent and/or abusive billing. This review would include evaluating the types of claims in question, any prior history of noncompliance and the length of time over which the behavior occurred.”

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