Assisted living operators that provide Medicaid home- and community-based services to their residents could be front and center in a new federal initiative aimed at clamping down on healthcare fraud.
Last week, Centers for Medicare & Medicaid Services Administrator Mehmet Oz, MD, asked state Medicaid directors to develop and submit two-year provider revalidation strategies. It also asked states to increase oversight of “high-risk” providers.
The provider revalidation strategies must include information about how states ensure the accuracy of provider enrollment data through revalidation or provider directory validation. CMS also called for states to adopt off-cycle or more frequent revalidation intervals than the minimum five-year requirements for providers states consider high-risk.
“CMS recognizes the significant challenges that states…
Insurance fraud involves making false or exaggerated claims to an insurance provider.
- Hard Fraud: Someone deliberately causes a loss (e.g., setting fire to a warehouse or staging a car accident) specifically to collect a payout.
- Soft Fraud: More common and often viewed as “victimless” by the perpetrator. It involves exaggerating a legitimate claim, such as overstating the value of stolen items in a home burglary to cover the deductible.