Reportedly, CMS summarily suspended these hundreds of providers based in part upon the task force’s AI-assisted reviews of billing data to identify potential fraud.
The Centers for Medicare and Medicaid Services (CMS) has reportedly issued notices of suspension of Medicare payments to hundreds of hospice facilities and a number of home health agencies in the Los Angeles area, citing potential fraud.
The suspensions are the latest imposed in connection with the federal government’s Task Force to Eliminate Fraud, established by executive order, that focuses federal resources on fraud prevention and “disrupt and dismantle fraud networks and facilitators.” Reportedly, CMS summarily suspended these hundreds of providers based in part upon the task force’s AI-assisted reviews of billing data to identify potential fraud.
Providers notified of such a suspension have a very short period in…
MANAGEMENT & CULTURE (THE “TONE AT THE TOP”)
Fraud thrives in “sloppy” environments where leadership ignores the rules.
- The Fraud Triangle: For fraud to occur, three elements must be present: Pressure (the need for money), Rationalization (thinking “I deserve this”), and Opportunity (weak controls). You can only control the Opportunity.
- Whistleblower Hotline: Provide an anonymous way for staff to report “odd behavior.” Most internal frauds are caught via tips, not audits.
- Background Checks: Conduct credit and criminal record checks for all employees in financial or data-sensitive roles.
- Annual Ethics Training: Make sure every staff member knows that the company has a Zero Tolerance policy toward “borrowing” from petty cash or fudging overtime.