Tuesday, January 20, 2015

CMS Final Rule: Requirements for Medicare Incentive Reward Program & Provider Enrollment

Dianne De La Mare
 
The US Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) has released a final rule, Medicare Program; Requirements for the Medicare Incentive Reward Program and Provider Enrollment, which is effective February 3, 2015. This final rule implements various provider enrollment requirements including: a) expanding the instances where a felony conviction can serve as a basis for denial or revocation of a provider or supplier’s enrollment; b) denying enrollment if the enrolling provider, supplier or owner has an ownership relationship with a previously enrolled provider or supplier that had a Medicare debt; and 3) enabling the federal government to revoke Medicare billing privileges if the provider or supplier has a pattern or practice of submitting claims that fail to meet the Medicare requirements; and d) limiting the ability of ambulance suppliers to “back bill” for services performed prior to enrollment.
 
Specifically, the following major provider enrollment provisions in the final rule are important for skilled nursing facilities (SNFs) to be aware of and understand:
  
  • CMS will deny enrollment when a provider, supplier or owner was previously the owner of a provider or supplier that had a Medicare debt that existed when the its enrollment was voluntarily terminated, involuntarily terminated or revoked; and: 1) the owner left the provider or supplier that had the Medicare debt within 1 year of that provider or supplier’s voluntary termination, involuntary termination or revocation; 2) the Medicare debt has not been fully repaid; and 3) CMS determines that the uncollected debt poses an undue risk of fraud, waste or abuse. In this situation, a denial can be averted if the enrolling provider, supplier or owner satisfies the criteria in 42 CFR Section 401.607 and either agrees to a CMS-approved extended repayment schedule for the entire outstanding Medicare debt or repays the debt in full.
  • CMS will deny enrollment or revocation of Medicare billing privileges if, within the preceding 10 years, the provider, supplier, owner or any managing employee, was convicted of a federal or state felony offense that CMS determines is detrimental to the best interest of the Medicare program and its beneficiaries.
  • CMS will allow revocation of Medicare billing privileges if the provider or supplier has a pattern or practice of submitting claims that fail to meet the Medicare requirements.
  • CMS is requiring all revoked providers and suppliers to submit all of their remaining claims within 60 days after the effective date of their revocation; with the exceptions as noted in section II.B.5 of this final rule.
  • CMS is limiting the ability of ambulance companies to back bill for services furnished prior to enrollment.
  • CMS is limiting the ability of revoked providers and suppliers to submit a correction action plan (CAP) to situations where the revocation was based on Section 424.535(a)(1).  
To obtain a copy of the final rule go to http://www.gpo.gov/fdsys/pkg/FR-2014-12-05/pdf/2014-28505.pdf.
 
 

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