By NextBestFitStricter provider enrollment
Background checks, site visits, and moratoriums on new providers in high-fraud categories.
Stops fraud before payment.
Review ledgerHow this path connects
Addresses
Fraud and improper paymentsThis path
Stricter provider enrollment
Concrete changes if chosen
What would actually have to change in law, agencies, payment rules, or systems.
- Require background checks and site visits for new providers
- Use moratoria in high-fraud categories
Effects
Each effect has its own page: the evidence, the case that it is or isn't a real cost, and whom it affects.
What it fixes
- Fraud and improper payments
Background checks, site visits, and enrollment moratoriums target high-fraud provider categories and stop fraud before payment.
What it creates or worsens
- Adds paperwork, coordination, or complexity
Background checks, site visits, and enrollment restrictions slow legitimate new providers.
- Health professional shortage areas
Moratoriums on new providers in high-fraud categories can reduce access to care.
4 paths soften this
Loan forgiveness and service obligationsHealth professional shortage areasChosenHigher pay in shortage areasHealth professional shortage areasChosenPermanent telehealth coverageHealth professional shortage areasChosenFull practice authority for NPs, PAs, pharmacists, dental therapistsScope-of-practice limits waste capacityChosen
Who's affected
Who gains
- Taxpayers and public budgets
- Fraud and improper payments: Fraud and improper payments consume public funds and premiums.
- People with employer coverage
- Fraud and improper payments: Fraud and improper payments consume public funds and premiums.
Who loses
- Fraudulent operators and cybercriminals
- Fraud and improper payments: Fraudulent providers receive improper health payments.
- Hospitals, clinics, and care organizations
- Adds paperwork, coordination, or complexity: Background checks, site visits, and enrollment restrictions slow legitimate new providers.
- Rural residents
- Health professional shortage areas: Clinician shortages limit primary and mental health care access.
- Low- and middle-income households
- Health professional shortage areas: Clinician shortages limit primary and mental health care access.
- Residents of areas with too few health professionals
- Health professional shortage areas: Clinician shortages limit primary and mental health care access.
Where it has been tried
- CMS moratoria: Used for home health and ambulances.
- U.S. (CMS): CMS reported Miami-Dade’s active home health agencies grew from 385 in 2008 to 662 in 2012, a 15% compound annual increase, and that 56% had not billed continuously since 2008, a category including new entrants rather than necessarily intermittent billers.