Committee Seeks Details of CMS Provider Screening, Fraud Prevention

The House Energy and Commerce Committee has asked CMS Administrator Marilyn Tavenner for answers to detailed questions about the agency’s efforts to combat fraud through screening of providers and checks of databases as well as its administration of the electronic health records (EHR) incentive payments authorized under the American Recovery and Reinvestment Act (ARRA) (P.L. 111-5). Committee chair Fred Upton, vice-chair Michael Burges, a physician; and chair emeritus Joe Barton signed a February 26 letter to Tavenner seeking a briefing by March 12, 2014.

Recent Reports of Fraud

The letter cited recent reports concerning fraud committed by a chain of six Texas hospitals which received $18 million in EHR incentive payments despite reports of fraud and substandard care that allegedly caused patients’ deaths, over a four-year period. Joe White, former chief financial officer for Shelby Hospital, has been indicted for presenting fraudulent claims for EHR payments. It is alleged that White’s attestations of meaningful use were false because the hospital depended upon paper records for the entire year. In order to appear to qualify for the EHR payments, White allegedly directed hospital employees and vendor staff to enter data into patients’ electronic records long after the patients had been discharged. In addition, White is alleged to have forged the signature of a staff member and used a Social Security Number that he obtained without her knowledge or consent to claim payments.

The Committee’s Questions

The details that the committee seeks extend well beyond the administration of the EHR incentive program. They focus on CMS’ implementation of provisions of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) imposing provider screening requirements and on zone program integrity contractors, which were introduced in 2007. Specifically, the committee asked about:

  • The status of the agency’s predictive modeling efforts;
  • The accomplishments of zone program integrity contractors (ZPICs) during the last year;
  • The actions CMS has taken to screen providers against the Social Security Administration’s Master Death File and the lists of debarred or excluded contractors maintained by the General Service Administration (GSA), the FDA, and the HHS Office of Inspector General (OIG);
  • A list of all providers excluded from Medicare participation since 2004;
  • How CMS knows that it is receiving notifications of credible allegations of fraud; and
  • Its legal authority for suspending payments to providers or recipients who are the subjects of fraud investigations.