Grassley Fights Fraud, Waste and Abuse in Medicare, Medicaid, CHIP

Press Release

Senator Chuck Grassley today introduced a wide-ranging bill to fight fraud, waste and abuse in Medicare, Medicaid and the Children's Health Insurance Program.

"This bill brings together common sense, bipartisan initiatives to fight fraud, waste and abuse in taxpayer-sponsored health care programs, which all face serious budgetary challenges," Grassley said. "As spending on these programs continues to grow, Congress should act quickly to pass these reforms out of respect for taxpayers and on behalf of program beneficiaries."

Grassley said his bill includes provisions that would:

*deter fraud with enhanced screening to improve the government's ability to keep fraudulent providers from participating in these programs from the start;
*limit tax dollars lost to fraud by giving the government more time to evaluate the legitimacy of Medicare providers before payment is required when fraud, waste and abuse is suspected that is allowed under the existing pay-and-chase model;
*strengthen the government's ability to detect fraud with better disclosure requirements;
*enhance coordination among federal agencies responsible for fighting fraud, including sharing data sources; and,
*improve enforcement capabilities by expanding the range of activity subject to penalties and toughening existing penalties.

Grassley said the "Strengthening Program Integrity and Accountability in Health Care Act" is comprised of reforms with bipartisan support. Grassley led the development of a number of these provisions during the bipartisan work in the Senate last year on comprehensive health care legislation. The Medicare payment reform measure also was introduced by Grassley in November (S.2774).

In addition, today's bill includes portions of bipartisan legislation Grassley introduced nearly a year ago (S.458) to fortify the Federal False Claims Act. The measures are a response to federal court decisions that have limited the scope and applicability of the FCA. They would restore the original Congressional intent of the highly effective updates to the FCA in 1986. Grassley was the principal Senate author of those whistleblower updates to the law that has recovered more than $22 billion for the U.S. Treasury that otherwise would have been lost to fraud. The law has become the government's most effective tool against health care fraud.

The Strengthening Program Integrity and Accountability in Health Care Act Bill Summary

Strengthen the Federal Government's Ability to Prevent Medicare, Medicaid and CHIP Payments from Going to Fraudsters

*Strengthen screening requirements
*Increase disclosure requirements
*Establish temporary moratorium authority
*Establish provider compliance program requirements
*Clarify obligations concerning provider overpayments
*Strengthen payment policies so that government doesn't "pay and chase"
*Require mandatory payment suspension pending investigation of credible allegation of fraud
Extend period of time that claims are paid under prompt payment rule if there is determination of likelihood of fraud, waste and abuse
*Create authority for provisional period of enhanced oversight for new providers that includes prepayment review
*Require payment adjustments for providers with past-due obligations
* Ensure that bona fide providers are billing Medicare, Medicaid and CHIP
*National Provider Identifier (NPI) required on all enrollment and claims forms
*Providers ordering items or services must be Medicare-enrolled or eligible
* Ensure that providers are billing for bona fide items and services
*Require documentation for certain items and services
*Require face-to-face evaluation before making determination of eligibility for item or service
* Strengthen and grant authority to expand surety bond requirements
* Reduce maximum period in which claims are submitted from three years to one year
* Prohibit Medicaid payments for unapproved drugs

Strengthen the Federal Government's Ability to Monitor and Detect Fraud, Waste and Abuse
* Streamline and consolidate federal data sources for purposes of fighting fraud, waste and abuse
* Strengthen data matching and access to data among federal agencies
* Create medical ID theft information sharing program and clearinghouse

Strengthen Federal Government Enforcement
* Strengthen the False Claims Act
* Establish a Medicare Self-Referral Disclosure Protocol
* Enhance Civil Monetary Penalties
* Expand activities that are subject to CMPs
* Expand activities that are subject to permissive exclusion
* Require administrative remedy for beneficiaries that knowingly participate in health care fraud schemes
* Clarify the intent requirement for health care fraud
* Expand testimonial subpoena authority for exclusion-only cases
* Expand Recovery Audit Contractor (RAC) Program to Medicaid and Medicare Part C and

Part D

Increase Funding for Fraud, Waste and Abuse
* Annual increases in Health Care Fraud and Abuse Control (HCFAC) Account funding for next ten years
* Permanent annual increases in HCFAC funding to adjust for inflation

Increase Accountability
* Strengthen reporting requirements for Medicare and Medicaid Integrity Programs
* Require response by HHS Secretary to OIG Management Implication Reports (MIRs)
* Require provider cooperation with Congressional Committee oversight and investigations

Source