The American Hospital Association is asking CMS to ensure that any fraud, waste and abuse-related changes are data-driven and do not add unnecessary administrative burden on hospitals.
The organization submitted a letter to CMS on March 30 in response to the agency’s request for information on its Comprehensive Regulations to Uncover Suspicious Healthcare (CRUSH) initiatives. CMS was seeking comments to inform potential future rulemaking on fraud prevention efforts.
The AHA estimated that an average-sized hospital with 161 beds spends more than $562,299 per year on regulatory compliance.
“Hospitals are ever mindful of their obligation to properly bill for the services they provide to Medicare, Medicaid and Children’s Health Insurance Program patients and incur great costs to do so,” the AHA said.
The AHA said that certain Medicare Advantage organization coverage and reimbursement practices “would benefit from additional regulatory oversight and scrutiny to prevent FWA.”
“These include complex prior authorization requirements and opaque coverage rules, network inadequacy and mid-year changes, restrictive and often proprietary medical necessity or coverage criteria and the impacts of MAO vertical integration,” the AHA said.
The AHA encouraged CMS to use existing data it already collects to inform audits and enforcement and to clarify that the MA noninterference clause does not broadly bar federal oversight of MA plan compliance.
In its letter, the AHA also recommended that CMS leverage and strengthen its existing oversight tools in Medicaid and CHIP, and that recent transparency and accountability initiatives be evaluated before any new policy changes are proposed.
The group also said AI could help mitigate fraud, waste and abuse but raised concerns about its use, recommending strategies such as mitigating the risk of hallucinations in AI coding tools, curtailing inappropriate downcoding and automated payment reductions by insurers, ensuring insurer transparency on AI use and providing independent physician review of coverage denials.
Read the full letter here.
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