“In the midst of a raging, all-hands-on-deck battle, the rules of engagement tend to change fast. That’s one way to understand the move by the Centers for Medicare & Medicaid Services (CMS) to relax their standard rules in the face of the health care response to COVID-19, on everything from licensing to reimbursements and well beyond. CMS is looking for every possible way to make it easier for care providers to respond to this once-in-a-lifetime challenge.”
“When the rules are relaxed, however, it’s also easier for fraudsters to seize a once-in-a-lifetime opportunity to cheat the system. While fraud in health care presents a persistent, year-over-year challenge (more than $68 billion per year according to the National Health Care Anti-Fraud Association) to state governments seeking to balance quality care with effective cost management, the scale of potential fraud opened up in the wake of these changes to CMS rules is simply beyond anything our health care infrastructure and state governments have encountered before. This fraudulent activity occurs at a moment when health care providers (from entire hospital systems to individual providers) are encountering a steep drop in incoming revenue as the virus response dominates health care. On top of everything else, now many have to worry whether they can stay afloat over the long term.”
“All these factors point to fraud emerging as one of the top ‘second-wave’ challenges in the months following the initial battle to contain the virus. While governors and their staffs are focused on securing beds and ventilators today, tomorrow they’ll be focused on containing massive, system-wide fraud.”
“Conducting manual reviews and audits in this environment, at this scale, is an unrealistic goal. Which is one reason why governors are implementing AI- and machine-learning enabled analytics capabilities for identifying the faint signals of fraud hidden in massive amounts of readily available data.”
“What does fraud look like in this new, relaxed-rules environment? And how can analytics tools be used to identify, anticipate, and actively reduce fraud? Here are a few prime examples of fraud that governors and Medicaid directors should expect to encounter very soon – and the analytics techniques that can help…” Read the full article here.
Source: Combating health care fraud as CMS loosens rules to respond to coronavirus – By Marty Bobroske, May 18, 2020. Federal News Network.
