New payment models clash with fraud laws; waivers might not be the answer, official says

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Nursing homes will be subject to escrow for all civil monetary penalties, CMS announces
Nursing homes will be subject to escrow for all civil monetary penalties, CMS announces

Healthcare payments linked to the quality of care are causing challenges to existing fraud and abuse laws, a government official said Wednesday.

New payment models, including accountable care organizations, create a potential program integrity risk by co-existing with fee-for-service programs, said Vicki Robinson, Department of Health and Human Services Office of the Inspector General, during remarks at the National Healthcare Anti-Fraud Association's Annual Training Conference.

Robinson also listed business relationships with non-traditional healthcare providers, insurance exchange payment accuracy, electronic health records and consumer fraud schemes as being other risk areas in 2015, according to the Bureau of National Affairs.

Long-term care has been pushed to embrace accountable care organizations in an effort to reduce re-hospitalizations. But Robinson noted some participants in the Medicare Shared Savings Program said they couldn't achieve the program's benefits while staying mindful of current fraud and abuse laws, which has led to some waivers in fraud regulations.

“It's not a comfortable place to be in when you're waiving fraud and abuse laws,” Robinson said, according to BNA. “The jury's still out on whether our approach to the waivers is working.”

The OIG said this week that that nursing home oversight was a top challenge.