Contagious Disease Current Events Medicaid/Medicare

Fighting fraud sensibly in a global pandemic

COVID-19 has wreaked havoc for patients, family, the economy and the health care system. In an attempt to provide support to families and businesses, the Coronavirus Aid, Relief, and Economic Security (CARES) Act injects funding into the economy. Further, regulations have been relaxed. As Michael Adelberg and Melissa Garrido write today in the Health Affairs blog:

…the Trump administration has taken a number of steps to relax long-established regulatory requirements and processes in the interest of increasing the capacity of the health care system to address COVID-19 and allowing distressed providers to focus solely on patient care.

Adelberg and Garrido argue that relaxing these regulations may allow unethical providers to engage in “wasteful and fraudulent activities”. The article wisely describes efforts by the Office of the Inspector General (OIG), Department of Justice (DOJ) and other government agencies to crack down on fake COVID-19 tests and treatments. The article also details some payer-focused Medicare and Medicaid regulations that have been relaxed including:

signatures for certain health care services, prior authorization requirements, reimbursing for offsite services, provider enrollment rules, reimbursing services without a written physician order, increasing the range of reimbursable ambulance services, services and drugs from network providers and pharmacies, and audits of providers and health plans. 

The authors mention that “compelling health policy arguments for relaxing regulatory processes and requirements during a national emergency”, but also state that “…history suggests that bad actors take advantage of leniency, and agency leaders have just offered great leniency”

All Adelberg and Garrido’s points are valid, but I believe they do not fully comprehend the cost of these regulations. Requirements for signatures, priori authorization, decreased flexibility for ambulance services all restrict physicians and other health care providers from giving patients the care they need. The authors note that Medicare and Medicaid improper payments totaled in the tens of billions of dollars. Yet even if these figures do rise, increasing access to care in a pandemic is likely well worth the cost. A more balanced discussion of the tradeoffs of regulation and the ability to be flexible/innovate in times of crisis are needed. A bigger issue will be determining which of the regulations should be reimposed after the pandemic ends.

While the government should stay vigilant to reduce fraud and abuse, in the case of a global pandemic, less regulation and more flexibility is needed to be able to help patients and providers get through this difficult time and minimize the loss of life.

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