New Anti-Fraud Provisions in PPACA Require Executive Criminal Checks - Government

Terri Bernacchi, PharmD, MBA, Health Advisory Professionals  

As the elements of the Patient Protection and Affordable Care Act (PPACA), as amended by the Health Care and Education Reconciliation Act of 2010 (collectively known as the Affordable Care Act, or the ACA) have begun to be formulated as regulatory rules that providers and other health care players must conform to, it is clear that some of the anti-fraud provisions are more onerous in terms of requirements and penalties than previous laws.  

Under the proposed rules, for example, newly enrolling home health agencies and suppliers of durable medical equipment (which are considered at “high risk” for fraud) will be subject to fingerprinting and background checking.  The provision would apply to apply to the owners, authorized or delegated officials, and managing employees, who theoretically would be more likely to get a financial gain from the act of fraud.

The law itself (under Section 6401(a)) grants the Secretary new and wide discretion to impose temporary moratoria on the enrollment of new Medicare, Medicaid, or CHIP providers and suppliers specifically to prevent or combat fraud, waste, or abuse.  

An October 6, 2010 white paper has been written and is available in the public domain by the National Health Care Anti-Fraud Association.  This URL link should take the reader to that paper:  http://www.nhcaa.org/eweb/docs/nhcaa/PDFs/Member%20Services/WhitePaper_Oct10.pdf

While the problem of health care fraud is a long-standing one for the private and government sector alike, the requirements posited under these regulations will add administrative cost and burden for health care providers.  The money required to build and maintain the government infrastructure for the fraud background screening and program integrity activities will be covered, in part, by the imposition of new $500 fees on the providers and suppliers. (Gee, I wonder if they’ll pass that cost along to patients and other payers?)  Theoretically, however, the costs will be more than offset by savings due to less fraud.  

CMS continues to take comments on its Proposed Rules for screening providers, asking providers and suppliers to submit comments, accepted until 5:00 p.m. on November 16, 2010. 

Terri currently works for a large health sciences firm serving payers, pharmaceutical and device manufacturers and other stakeholders in health care as a Senior Principal in Managed Markets.  The thoughts put forth on these postings are not necessarily reflective of the views of her employer nor other Health Thought Leader colleagues.  Terri has had a varied career in health related settings including:  9 years in a clinical hospital pharmacy setting, 3 years as a pharmaceutical sales rep serving government, wholesaler, managed markets and traditional physician sales, 3 years working for the executive team of an integrated health system working with physician practices, 4 years as the director of pharmacy for a large BCBS plan, 12 years experience as founder and primary servant of a health technology company which was sold to her current employer three years ago.   She has both a BS and a PharmD in Pharmacy and an MBA.