CMS Introduces New Rules To Improve Service And Fight Fraud

The Centers for Medicare and Medicaid have introduced new regulations to improve service and prevent fraud.
by , | October 4, 2011

The Centers for Medicare and Medicaid announced on Monday a series of new regulations under the Affordable Care Act that would improve Medicare efficiency and coverage while preventing fraud, according to a department press release. The proposed rules would take effect in 2013 once finalized. CMS will hold a 60-day period for public comment following the publication of the proposal.

The new rules would:

  • Improve Medicare's Part D Coverage by expanding the number of drugs covered by the plan, including prescriptions used to treat anxiety disorders and seizures, as well as drugs for anesthesia under certain conditions.
  • Allow physicians to request reconsiderations by an Independent Review Entity if prescriptions under a patient's Part D coverage are denied without requiring them to obtain a signed authorization form.
  • Allow CMS to terminate poorly performing Medicare Advantage and Part D sponsors that have failed to receive a three-star rating from CMS over a three-year period.
  • Expand benefits and increase flexibility for those receiving both Medicare and Medicaid, allowing such individuals to access supplemental benefits like non-skilled nursing activities in the home and in-home food delivery for those eligible.
  • Streamline claims' filing to prevent fraud. Pharmacy benefit managers would be required to provide additional financial information to increase transparency, which would allow for improved data collection and enable law enforcement to more easily investigate suspected fraud.

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