With respect to incentives, CMS said it would not proceed for now with a proposal to boost maximum whistleblower awards to $9.9 million from $1,000. The proposed increase was inspired by an Internal Revenue Service incentive program that helped claw back $1.6 billion from 2007-12, but CMS said it concluded that extending such incentives to the health care space would be problematic.
For one, the agency worried that a sharp uptick in whistleblower reports would mostly alert regulators to “irrelevant or erroneous information” and thereby “impose a heavy burden on CMS and its contractors” without generating much return on investment.
“Providers would also be seriously burdened because they would constantly have to fight unwarranted complaints,” CMS wrote in the final rule.
The agency also planned to limit reward eligibility to the first reporter of fraud, much like the False Claims Act limits rewards to the original sources of information. But commenters reportedly warned that such a policy would create a “shoot first, ask questions later" situation, perhaps because quietly tipping regulators is less of a commitment than filing a lawsuit.
CMS also said it heard concerns that dangling such enormous financial carrots would badly undermine internal compliance systems at hospitals, which are supposed to have elaborate mechanisms for employees to report questionable billing without retaliation.
“Due to the complexity of the operational aspects of our proposal, we are not finalizing our proposed [incentive] provisions in this rule,” regulators wrote Wednesday. “We may finalize them in future rulemaking.”
Under the terms of the proposal, the maximum reward CMS could pay for information leading to recovery of Medicare funds would have been upped to 15 percent of the recovery, to a maximum of $9.9 million, from the current 10 percent of the amount recovered, with a cap of $1,000.
A public docket shows that a number of groups expressed alarm about the stepped-up incentives, including the American Medical Association, which described itself in a June 2013 letter as “very concerned that that the provision of a significantly increased award amount will encourage false reports.”
Wednesday’s regulation did preserve several other aspects of the April 2013 proposed rule, including a new ability to prevent enrollment of providers with unpaid Medicare debt, which typically stems from failure to return overpayments. The idea is to prevent entities from incurring debt, leaving Medicare and then re-enrolling as a new business to duck repayment obligations.
Another aspect of the regulation will let CMS block enrollment or revoke billing privileges when a health care company's owner or manager in the past decade has been convicted of a felony that the agency “determines to be detrimental to the best interests of the Medicare program and its beneficiaries.” According to the rule, those felonies would include medical malpractice, violent crimes and various financial offenses, including embezzlement and income tax evasion.
Another provision would allow revocation of billing privileges when providers consistently demonstrate an inability to comply with billing rules. Also, the rule would end the ability of ambulance companies to “back bill” Medicare for work performed up to one year before enrolling.
--Additional reporting by Daniel Wilson. Editing by Chris Yates.
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Source: http://docphy.com/business-industry/health-care/cms-backs-off-10m-anti-fraud-awards-whistleblowers.html
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