HCFA's Action Plan

Penny Thompson, director of Program Integrity for the Health Care Financing Administration (HCFA), outlined the agency's 10-point action plan at a congressional hearing last month to combat fraud and abuse in Medicare's partial hospitalization benefit. Here is a summary of the plan:

• Protect beneficiaries' access to covered services by working with the Administration on Aging and other federal agencies, mental health advocates, state officials, and others to ensure that beneficiaries receive appropriate services from Medicare.



• Terminate the worst offenders and make other community mental health centers (CMHCs) correct identified problems quickly.



• Increase scrutiny of new CMHC applicants by requiring site visits nationwide to ensure they meet all of Medicare's core requirements. Participation has already been denied to more than 100 applicants who failed to meet the criteria.



• Pursue President Clinton's proposed legislative reforms sent to Congress in January to strengthen CMHC enforcement activities including authorizing fines for falsely certifying a beneficiary's eligibility for partial hospitalization services, prohibiting partial hospitalization services from being provided in a beneficiary's home or other residential setting, and authorizing the HHS Secretary to set additional requirements for CMHCs to participate in the Medicare program.



• Intensify medical review of claims to ensure Medicare pays only for appropriate services to qualified beneficiaries. This will involve claims from CMHCs and hospital outpatient departments.



• Implement a prospective payment system for hospital outpatient services as required by the 1997 Balanced Budget Act. The new system will apply to partial hospitalization benefits in CMHCs and eliminate the financial incentives to provide inappropriate, unnecessary, or inefficient care.



• Conduct a broad evaluation of the partial hospitalization benefit with the inspector general in CMHCs and hospital outpatient departments. Appropriate steps will be taken to address problem areas identified during that review.



• Reinforce Medicare's statutory and regulatory standards for CMHCs to participate in the program through HCFA's regional offices and state survey agencies.



• Evaluate the need for new requirements for CMHCs such as reenrolling periodically in the Medicare program and serving a minimum number of non-Medicare patients.