The Department of Health and Human Services (HHS) said solving Medicare and Medicaid fraud is a top management challenge, and despite recent success in cracking down on such fraud, there are many roadblocks to overcome in further reducing criminal activity in the programs.

HHS said a main challenge in fighting fraud is effectively using the Centers for Medicare & Medicaid Services’ (CMS’) provider enrollment and payment suspension authorities against those providers and suppliers that have exploited weaknesses to commit fraud rather than provide legitimate patient care.

Other challenges are managing HHS’ expanding use of data analysis and excluding individuals and entities from federal health care programs to protect beneficiaries.

The department said the Affordable Care Act (ACA) addressed many program vulnerabilities by authorizing rigorous enrollment and screening processes, enrollment moratoria, and payment suspension.

A year ago February, CMS published a final rule implementing the ACA provisions concerning screening of providers and suppliers based on fraud risk.

“Enhanced data analysis is made possible by the impressive enforcement results of the nine Medicare Fraud Strike Forces, which are part of the Health Care Fraud Prevention and Enforcement Action Team,” HHS said.

“The strike forces are interagency teams of prosecutors and federal and local law enforcement that focus enforcement resources on geographic areas at high risk for fraud.”

In June 2011, CMS implemented the Fraud Prevention System to risk-score Medicare Fee-for-Service claims prepayment and awarded a contract to IBM in July 2011 to develop and test new predictive

HHS said although the CMS final rule on enrollment screening takes important steps toward preventing fraud, there are additional opportunities for CMS to strengthen the enrollment system, including adopting a more flexible screening approach, tailoring screening measures to fraud risks, and classifying re-enrolling home health providers as “high risk.”