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The New Strategy to Fight Medicare Fraud

An interview with the man leading the federal battle against medical cons

Shantanu Agrawal, director of program integrity at Centers for Medicare and Medicaid Services

Pablo Martinez Monsivais/AP

Shantanu Agrawal, Director of Program Integrity at the Centers for Medicare & Medicaid Services, shares what government is doing to prevent medical fraud.

Shantanu Agrawal, director of program integrity at the Centers for Medicare & Medicaid Services (CMS), talks about his mission to detect and prevent waste, abuse and medical fraud.

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Q: Why is fraud hard to stop?

A: Medicare is a very large system. We get 4.5 million claims a day. We make over $1 billion of payments a day. That kind of volume is inherently a challenge. We are larger than the largest private payers in the country.

But Medicare is a far more open system than almost any private payer. If our providers meet a base set of requirements, we are required by law to allow them to enter the program, treat patients and bill for those services.

Q: What is CMS doing differently to control future fraud?

A: Our focus, since the Affordable Care Act, has been to move from a primarily retrospective recovery-based model to one that is prospective and corrective. A lot of our reviews are now done on a prepay basis, before claims are paid. We can suspend 100 percent of a provider’s payments. We have [made] thousands, if not tens of thousands, of site visits over the last two years to find false storefronts. We are working with private payers in data exchange to identify common vulnerabilities and common providers of concern, which has saved hundreds of millions of dollars.

Related story: The war on Medicare fraud

Q: What about the “doctors” without licenses who get away with fraud?

A: Historically, getting up to speed on medical license data was a challenge. We have made great progress using the new tools and authorities of the Affordable Care Act to ensure that we are working with the right providers. We connected over 100 different databases at the state and federal level that look specifically at medical licensure. That has led to over 500,000 providers [being] removed from the billing system. We estimate that’s saved taxpayers $2.5 billion over the past five years. That puts us on a different footing.

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