The Future of Medicare Program Integrity

CMS is developing a five-pillar program integrity strategy to modernize approach and protect Medicare for future generations.

• Stop Bad Actors. Work with law enforcement agencies to identify and take action on those who defraud the Medicare program. CMS, Office of the Inspector general (OIG), Department of Justice (DOJ), and the Unified Program Integrity Contractors (UPICs) jointly deliberate on potential healthcare fraud cases, quickly direct them to law enforcement, and take appropriate administrative action such as payment suspensions and revocations. 
• Prevent Fraud. Improving infrastructure that prevents fraud, waste and abuse on the front end. After identifying bad actors and their schemes, make system changes to avoid similar fraudulent activities in the future. 
• Mitigate Emerging Programmatic Risks. The proposed changes also give the flexibility to respond to future data and trends and tailor strategies accordingly. Implementing prior authorization for these items as well as additional items in the future will help ensure that services billed are medically necessary.
• Reduce provider burden. Increased efforts to educate providers in CMS program rules and regulations and remedy onerous processes to assist rather than punish providers who make good faith claim errors.

CMS is collaborating with ongoing industry efforts to streamline workflow access to coverage requirements, starting with developing a prototype Medicare FFS Documentation Requirement Lookup Service.

CMS is currently exploring ways to centralize screening and continuous monitoring for all payers.

Leverage New Technology. CMS is seeking new, innovative strategies and technologies, perhaps involving artificial intelligence and/or machine learning, which are more cost effective and less burdensome to both providers, suppliers and the Medicare program. This new technology could allow the Medicare program to review compliance on more claims with less burden on providers and less cost to taxpayers.

Source: https://www.cms.gov/blog/future-medicare-program-integrity