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New Anti-Fraud Safeguards Under ACA Impact Medicare Billing Privileges

  • by Margaret Klasa DC, APN BC
  • Dec 16, 2014, 09:04 AM

 Context_Medicare_Billing_Compliance_ACA_Anti-Fraud_SafeguardsAs a result of new anti-fraud measures under the Affordable Care Act (ACA), the Centers for Medicare & Medicaid Services (CMS) finalized a policy on December 3, 2014 which would revoke or deny Medicare billing privileges from providers that routinely bill for services that do not meet Medicare requirements. This 140 page rule will stop providers from coming back into the system and is designed to protect patients. 

Both CMS and provider groups agree that fraud must be cut, and that inadvertent billing errors and interpretation differences are common when complex services are billed to Medicare.

In addition to denying providers due to inappropriate billing practices, CMS will reject suppliers and owners affiliated in any way with others that have Medicare debt in an effort to stop people from re-enrolling and exiting the program only to re-enroll as a new business.

According a Modern Healthcare article posted on December 3, 2014, president-elect Dr. Wanda Filer of the American Academy of Family Physicians (AAFP), acknowledges that CMS has not responded to "what defines the pattern or practice of inappropriate billing.” The concern on the providers’ side is that the pattern of detection is so complex that a provider could make an error and be overly adjudicated without due process. Not only will providers be harmed but the patients as well. When this issue was raised when the policy was introduced, CMS responded by claiming they wanted to maintain flexibility by not specifically defining what actually determines the “pattern or practice of abusive billing.”


To ensure your claims are compliant with industry changes and other payer requirements, Contexts offers our ClaimsEditor Online™ claim editing solution. Our solution contains current NCCI, clinical, and technical edits. These edits range from basic checks for accuracy of codes, appropriate use of modifiers, and validation of patient gender and age, to complex relationships such as instances of code fragmentation, utilization violations, mutually exclusive services, diagnosis/procedure relationships, and more. ClaimsEditor Online™ can be easily and seamlessly integrated into your existing billing or Electronic Health Record (EHR) process.

Want more Compliance Edge? Read this related article: CERT Program Monitors CMS FFS Improper Payments - $36 Billion in 2013

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