New efforts to prevent and catch fraud within CMS programs require stronger safeguards for DSOs, according to Barry Lyon, DDS.
CMS recently 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.
Dr. Lyon, director of provider recruiting and onboarding at Dental Care Alliance, recently spoke with Becker’s about what the new enforcement initiative means for DSOs.
Dr. Barry Lyon:
Medicaid fraud has clearly gotten the attention of the federal government. The Department of Justice is actively pursuing healthcare fraud with gusto. Whistleblowers now have plenty of company.
The government is no longer only going after big-time fraud offenders. Instead, there’s a coordinated effort by the Department of Health and Human Services using the False Claims Act to try and recover as many ill-gotten payments as possible. The risks to dentists and DSOs have increased significantly with a bullseye on Medicaid.
The most significant change, however, is not just how active the DOJ is. It’s how it’s being done. Advanced analytics and artificial intelligence are used to discover fraud that was once under the radar. Regulators are no longer waiting for whistleblowers or complaints; they are proactively scanning for variances in utilization, coding patterns and provider behavior. For DSOs, this means that scale, once a strategic advantage, amplifies risk. A single documentation or coding issue, when multiplied across dozens or hundreds of providers, can quickly escalate into a material compliance exposure.
For DSOs, compliance can no longer simply be an add-on. It must be entrenched into clinical operations, revenue cycle management and executive oversight.
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