CMS is committed to preventing fraud and protecting people with Medicare from falling victim to fraud. We take swift actions to prevent payments from going to bad actors when we have credible allegations of fraud. While bad actors will always exist, our fraud prevention efforts are working.  

In early 2023, CMS identified a concerning rise in urinary catheter billings attributed to a small group of 15 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) companies that had recently changed ownership. Through investigative work, CMS determined that people with Medicare did not receive catheters from these DMEPOS companies and were not billed directly, physicians did not order these supplies, and the supplies were not needed.

This case study (PDF) details how CMS’ swift action to stop payment of these suspicious claims prevented more than $4.2 billion in payments from going out the door. 
 

The Healthcare Fraud Prevention Partnership (HFPP) has released its latest white paper, "Measuring the Value of Healthcare Anti-Fraud Efforts" (PDF). Authored by researchers at Boston University, this white paper captures the value of efforts to combat healthcare fraud with a focus on deterrence as an important element of return on investment (ROI). 

Efforts to combat healthcare fraud are critical to the long-term financial sustainability of health insurance programs and patient safety. Payers undertake extensive measures to combat fraud, such as conducting pre- and post-payment reviews, member education, and criminal and civil litigations, as well as enforcing regulations directed at eliminating fraud. When evaluating the effectiveness of these initiatives, ROI is often used as a key metric, measuring net value against costs.

Calculating ROI with the inclusion of deterrence ensures fraud-fighting efforts are properly captured, minimizing the potential of undervaluing such initiatives. Information from HFPP Partner interviews and case studies featuring Medicare claims data reveal that when both the impact of deterrence and recovery are included in financial returns, ROI is higher by a factor of 2 to 10 – even when conservatively measured. 

This HFPP resource outlines detailed strategies to improve ROI measurement for fraud prevention efforts, including moving from a “pay and chase” model to a preventive one. 

For more information, please see:

• Measuring the Value of Healthcare Anti-Fraud Efforts HFPP White Paper (PDF)
• White Paper Information Sheet (PDF)

CMS recognizes that it is important for stakeholders to understand how CMS anticipates performing medical review after the Public Health Emergency (PHE) has ended. Below is an FAQ that addresses how our review contractors (Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs) and the Supplemental Medical Review Contractor (SMRC)) plan to conduct medical reviews post PHE.

Q. At the end of the Public Health Emergency (PHE) how will CMS’ review contractors conduct medical reviews for claims billed during the PHE based on approved waivers or flexibilities?

A. CMS contractors (MACs, RACs, and SMRC) review a very small percentage of Medicare Fee-for-Service claims each year. During the PHE, flexibilities were applied across claim types. For certain DME items, this included the non-enforcement of clinical indications for coverage. Since clinical indications for coverage were not enforced for certain DME items provided during the PHE, once the PHE ends CMS plans to primarily focus reviews on claims with dates of service outside of the PHE, for which clinical indications of coverage are applicable. We note that we may still review these DME items, as well as other items or services rendered during the PHE, if needed to address aberrant billing behaviors or potential fraud. The HHS-Office of the Inspector General may perform reviews as well. All claims will be reviewed using the applicable rules in place at the time for the claim dates of service.

For more information about medical reviews and the claims process, please visit the Medical Review and Education page.