ADA wary of impact CMS’ antifraud program could have on dentistry

The American Dental Association has expressed concerns about the new antifraud program developed by CMS, according to an April 2 news release from the ADA. 

Here are eight things to know:

1. CMS has proposed the Comprehensive Regulations To Uncover Suspicious Healthcare, or CRUSH, initiative, which is designed to stop suspicious payments across Medicare, Medicaid and the Health System Insurance Marketplace.
2. The initiative will leverage advanced AI and real-time data analytics to prevent taxpayer funds from leaving the system for suspicious requests. 
3. One of the potential requirements is that all providers must be enrolled in traditional Medicare to participate in Medicare Advantage plans. The ADA said that the policy would likely discourage dentists from participating in Medicare programs. 
4. The potential reduction in dentist enrollment could undermine CMS’ efforts to improve access to care. 
5. The ADA is also opposed to expanding authority for Medicare Advantage and Part D plan sponsors to suspend payments, saying that it would disproportionately affect dental providers. Dental practices typically only participate in Medicare Advantage through supplemental benefits. 
6. Temporary suspensions of reimbursements during investigations could harm dental practices, many of which operate on thin margins and rely on steady reimbursements. 
7. The organization cautioned the potential use of AI in the CRUSH initiative, as dentistry has limitations to data quality and interoperability. Dental claims data are structured more for benefit administration, and not for determining medical necessity or detecting fraud. 
8. The ADA pushed for CMS to invest in dental data infrastructure and prohibit insurers from using AI as the sole basis for claim denials or prior authorization decisions.

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