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HHS announces new tools and resources from the Affordable Care Act to prevent fraud and strengthen Medicare, Medicaid and CHIP

Posted Sep 19 2010 10:01pm

Proposed CMS regulation on display at federal register

The U.S. Department of Health and Human Services has issued new rules to help fight waste, fraud and abuse in Medicare, Medicaid and the Children’s Health Insurance Program (CHIP). These important new tools were made possible by the Affordable Care Act, which includes a series of provisions to fight fraud in the health care system. The rules will strengthen and expand CMS’ fraud prevention efforts – stopping fraud on the front end by keeping out criminals who pose as providers and prey on Medicare, Medicaid, and CHIP, and saving the Medicare Trust Fund money by avoiding fraudulent claims.

“These important provisions of the Affordable Care Act will not only help us crack down on criminals who are seeking to scam the system, but will also help us to save millions of taxpayer dollars in Medicare, Medicaid and CHIP –  three vital programs that more than 100 million Americans count on for their health care.” said HHS Secretary Kathleen Sebelius.  “Using these new fraud prevention measures, CMS will be able to move from a ‘pay and chase’ approach to one that makes it harder to commit fraud in the first place.”

HHS has also recently created a Center for Program Integrity at CMS that is focused on identifying and stopping fraud and acting swiftly to protect beneficiaries.

“While the majority of health care providers and suppliers are honest, we also know there are criminals who are looking for any opportunity to take advantage of beneficiaries and rip off Medicare, Medicaid, and CHIP” said CMS Administrator Donald Berwick, M.D. “Thanks to the new law, we will now have resources that will enable us to do more to prevent fraud and stop criminals from getting into the system in the first place."

The Affordable Care Act includes new provider screening and enforcement measures to help prevent and fight fraud.  In addition, the proposed rule contains important new authority to suspend payments when a credible allegation of fraud is being investigated.   

Specifically, the proposed rule will:

  • Establish the requirements for suspending payments to providers and suppliers based on credible allegations of fraud in Medicare and Medicaid;
  • Establish the authority for imposing a temporary moratorium on Medicare, Medicaid, and CHIP enrollment on providers and suppliers when necessary to help prevent or fight fraud, waste, and abuse without impeding beneficiaries’ access to care.
  • Strengthen and build on current provider enrollment and screening procedures to more accurately assure that fraudulent providers are not gaming the system and that only qualified  health care providers and suppliers are allowed to enroll in and bill Medicare, Medicaid and CHIP;
  • Outline requirements for states to terminate providers from Medicaid and CHIP when they have been terminated by Medicare or by another state Medicaid program or CHIP;
  • Solicit input on how to best structure and develop provider compliance programs, now required under the Affordable Care Act, that will ensure providers are aware of and comply with CMS program requirements.

“The rules proposed today are an historic step toward a new era in program integrity,” said Peter Budetti, director of CMS’ new Center for Program Integrity.  “We encourage input and feedback on this proposed rule to guide the implementation of the final regulations.”

To find out more about the new proposed rules to fight fraud in Medicare, Medicaid and CHIP visit

To find out more about how the Affordable Care Act is helping fight fraud and protect taxpayer dollars visit .

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