Some Areas in Dallas and Houston Labeled as High Fraud Areas for Medicare, Medicaid and CHIP

Fraud trends warranted a moratorium on home health providers and ambulance suppliers in some areas of Texas.

The Centers for Medicare & Medicaid Services (CMS) today announced new temporary moratoria on the enrollment of home health agencies in four metropolitan areas (Fort Lauderdale, Detroit, Dallas and Houston). This new temporary moratoria also includes the enrollment of new ground ambulance suppliers in the Greater Philadelphia area. CMS is also extending for six-months the current enrollment moratoria of home health agencies in Chicago and Miami and for Houston area ground ambulance supplier enrollments in its Medicare, Medicaid and Children’s Health Insurance Program (CHIP) operations.  This is the second wave of the agency’s use of this powerful tool to fight fraud and safeguard taxpayer dollars while ensuring patient access to care is not interrupted.

CMS Administrator Marilyn Tavenner said this action demonstrates how the Affordable Care Act continues to protect taxpayer dollars by moving the agency beyond “pay and chase” to prevent fraud in areas of known risk.  In July 2013, CMS’ initial use of the temporary enrollment moratoria authorities focused on three fraud “hot spot” metropolitan areas.

CMS also consulted with the Health and Human Services Office of Inspector General and the Department of Justice, and found that fraud trends warranted a moratorium on home health providers and ambulance suppliers in these geographic areas.  Part of the work included a review of key factors of potential fraud risk including a disproportionate number of providers and suppliers relative to beneficiaries, and extremely high utilization.  All the geographic areas named in the moratoria ranked high in these fraud risk factors.

“Our first use of the moratoria put fraudsters on notice that we are using all available tools, including these moratoria, to combat fraud, waste and abuse in our health care programs, while maintaining patients’ access to care,” Tavenner said.  “Today’s announcement shows we are continuing our intense fight against fraud, waste and abuse in these vital health care programs.”

The extension of the current moratoria applies to new enrollments for home health agencies in the Miami and Chicago metropolitan areas and to new enrollments for ground ambulance suppliers in the Houston metropolitan area (see the full list of new and extended moratoria counties below). Existing providers and suppliers can continue to deliver and bill for services, but no new provider and supplier applications will be approved in these areas.  The six-month extension of the moratoria in these areas and the imposition of new moratoria in the additional counties were announced in a notice issued today in the Federal Register.

The new moratoria and the six-month extension of the existing moratoria will begin Friday, January 31, and are expected to remain in place for a period of six months.  CMS may lift the moratoria earlier or extend it another six months by issuing another notice in the Federal Register.  During the moratoria period, CMS and the affected States will continue to monitor access to care to ensure that Medicare, Medicaid and CHIP beneficiaries are receiving the services they need. For all new moratoria counties where the moratoria was extended, CMS and affected States have carefully examined Medicare beneficiary access to home health and ambulance services and concluded that the moratoria will not affect access to care.

The Federal Register notice can be downloaded at: https://www.federalregister.gov/public-inspection\

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