The Collaborative submitted formal comments on the agency’s new Comprehensive Regulations to Uncover Suspicious Healthcare (CRUSH) initiative: fraud prevention in long-term and post-acute care
The LTPAC Health IT Collaborative strongly supports combating fraud, waste, and abuse in Medicare and Medicaid. Protecting taxpayer dollars and safeguarding vulnerable beneficiaries from predatory actors are priorities we share with CMS. That is why the Collaborative submitted formal comments on the agency’s new Comprehensive Regulations to Uncover Suspicious Healthcare (CRUSH) initiative: fraud prevention in long-term and post-acute care must reflect the realities of the populations served and the systems providers rely on every day.
A central message in the Collaborative’s response is that CMS needs better data, not just stricter rules. LTPAC providers often work with older, non-standardized technology systems and have not benefited from the same federal interoperability incentives that transformed health IT adoption in hospitals and physician practices. When modern fraud detection tools and AI models are applied to incomplete or poorly standardized LTPAC data, legitimate providers can be flagged unfairly. The letter urges CMS to improve interoperability and use longitudinal ancillary and care data — including pharmacy, lab, rehabilitation services, and radiology and imaging — to better distinguish true fraud from appropriate care delivery.
The Collaborative also emphasized that many billing irregularities in LTPAC are driven by eligibility complexity, not bad intent. Beneficiaries often move across settings such as hospital, skilled nursing, home health, and hospice, while Medicare and Medicaid eligibility can change over time and may not be visible in real time. Providers frequently submit claims in good faith based on the information available, then must later correct or rebill once eligibility is clarified. The letter calls on CMS to strengthen real-time eligibility verification and create safe harbors for good-faith billing errors so that systemic delays are not mischaracterized as fraud.
The Collaborative’s comments also stress that fraud enforcement tools can create serious patient harm if they are not carefully designed. In LTPAC settings, payment suspensions or prior authorization delays can interrupt medications, rehabilitation, lab monitoring, and other essential ancillary services that patients depend on. The letter recommends rapid appeals, continued payment for beneficiary-critical services during review, and a more graduated enforcement approach. It also points to lessons from Project PAUSE and the antipsychotic quality measure experience, which showed how data-driven policy without clinical context can produce unintended consequences and restrict appropriate care.
