The Centers for Medicare & Medicaid Services (CMS) announced that the Medicare fee-for-service (FFS) improper payment rate has continued to decline, translating to less fraud, waste, and abuse that can increase the fiscal burden on the nation’s healthcare system. CMS’ actions have led to an estimated $15 billion reduction in FFS improper payments over the past four years.
The FFS estimated improper payment rate decreased to 6.27 percent in fiscal year 2020, from 7.25 percent in fiscal year 2019, the fourth consecutive year the rate has been below the 10 percent threshold for compliance established in the Payment Integrity Information Act of 2019.
CMS said that this year’s decrease was driven largely by improvements in home health and skilled nursing facility claims. Improper payments represent payments that don’t meet program requirements—intentional or otherwise—and contribute to inaccurate spending of Americans’ tax dollars, but are not all representative of fraud, CMS said. Improper payments might be overpayments or underpayments, or payments where sufficient information was not provided to determine whether a payment is proper or not.
CMS developed a five-pillar program integrity strategy to modernize its approach to reducing the improper payment rate while protecting its programs for future generations:
· CMS works with law enforcement agencies to crack down on those who have defrauded federal health programs.
· Rather than the expensive and inefficient “pay and chase” model, CMS prevents and eliminates fraud, waste, and abuse on the front end by strengthening vulnerabilities.
· CMS is exploring ways to identify and reduce program integrity risks related to value-based payment programs by looking to experts in the healthcare community.
· To assist rather than punish providers who make good faith claim errors, CMS is reducing the burden on providers by making coverage and payment rules more easily accessible to them, educating them on CMS programs, and reducing documentation requirements that are duplicative or unnecessary.
· CMS is working to modernize its program integrity efforts by exploring innovative technologies like artificial intelligence and machine learning, which could allow the Medicare program to review compliance on more claims with less burden on providers and less cost to taxpayers.