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CMS Toolkits: Empowering Medicaid Providers, Beneficiaries, and Stakeholders with Educational Resources

on Monday, 15 June 2015 in Health Law Advisory: Zachary J. Buxton, Editor

The Centers for Medicare & Medicaid Services (“CMS”), through the Center for Program Integrity (“CPI”), provides educational resources for providers, beneficiaries, and other stakeholders to share best practices and increase awareness of federal health care program fraud, waste, and abuse. The program integrity functions of both Medicare and Medicaid were joined with the creation of the CPI. This coordinated approach, under the purview of the CPI, has allowed the CMS to strategically combat fraud, waste, and abuse. The toolkits reviewed in this article pertain to Medicaid providers, beneficiaries, and stakeholders, but the information contained within them has been developed and tested through this collaborative approach.

Currently, there are 16 different toolkits on a variety of topics, which are regularly updated, the most recent being the “Self Audit” toolkit. The toolkits include a plethora of educational and reference material for trainers and trainees. The information is presented in a variety of ways, including: video presentations with printable handouts; professional quality booklets, which provide additional in-depth information; helpful fact sheets that inform the reader of the topic’s “essential elements,” and other innovative strategies. All of the training materials include a resource handout with additional articles, links to administrative agencies, bulletins, and other material that supplement the toolkit information.

Highlights of existing toolkits:

Audit Toolkit: The training video is narrated and runs for approximately 32 minutes. The information is presented in a slide format, which allows trainees to follow along and take notes on the provided presentation handout. For compliance officers, the 22-page booklet serves as a trainer’s guide, reference material, and “how-to” manual for performing a self-audit. The fact sheet is intended as a reference for physicians and other health care professionals who may not have time to sit through the longer presentations or trainings; the information is bulleted and concise, hitting on all of the major learning points.

Fraud, Waste & Abuse Toolkit: This training is helpful as it addresses common types of fraud and abuse: medical identity theft; billing for unnecessary services and items; billing for services not rendered; upcoding; unbundling; billing for non-covered services or items; kickbacks; and beneficiary fraud. The fraud, waste, and abuse presentation video is approximately 60 minutes long and provides a variety of example scenarios that touch on all of the common types of fraud and abuse. In this toolkit, the fact sheet is helpful as a quick reference; it defines and identifies red flags for each of the aforementioned fraud and abuses. Additionally, the toolkit includes a “Laws Against Health Care Fraud” resource guide which identifies relevant anti-fraud and abuse federal laws. This is a helpful reference for compliance officers who may need to quickly reference these federal laws.

Safeguarding Your Medical Identity Toolkit: This toolkit contains information that is helpful for beneficiaries as well as providers. The presentation resource in this toolkit is unique; it allows for the participant to obtain continuing education credits for certain organizations. The fact sheet has specialized information for providers. It identifies risk factors, suggests how to mitigate those risk factors, and addresses remediation for victims of identity theft. For beneficiaries, the resource sheet provides links to relevant articles, regulations, statutes, and administrative bodies that help to inform beneficiaries on additional resources for more specific inquires.

There are also practice specific toolkits for providers of hospice care, dental care, nursing homes, pharmacies, managed care, and non-emergency medical transportation services. All of the practice specific toolkits have reference booklets and fact sheets; the “Managed Care Compliance” and “Non-Emergency Medical Transportation” toolkits have video presentations in addition to the in-depth booklets and fact sheets.

These toolkits can be a valued asset to any provider, beneficiary, or stakeholder who is looking to remain vigilant to any instances of Medicaid fraud, waste, and abuse. The information in these toolkits is current and informative and can function as a supplemental resource for existing training programs, or as a foundational piece for a new or revised training program.

The toolkits can be found here.

Sean T. Nakamoto
Summer Associate

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