Tuesday, March 1, 2016

CMS’ Proposed Changes to Medicare Provider Enrollment

On March 1, 2016, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule, Program Integrity Enhancements to the Provider Enrollment Process, that would implement the Affordable Care Act (ACA) provider enrollment provisions to prevent questionable providers and suppliers from entering the Medicare program upfront, and to enhance the agency’s ability to act in instances of improper behavior. Key provisions in the proposed rule include:
  • Disclosure of Affiliations: Health care providers and suppliers would be required to report affiliations with entities and individuals that: 1) currently have uncollected debt to Medicare, Medicaid, or Children’s Health Insurance Program (CHIP); 2) have been or are subject to a payment suspension under a federal health care program or subject to an Office of Inspector General (OIG) exclusion; or 3) have had their Medicare, Medicaid, or CHIP enrollment denied or revoked. CMS could deny or revoke the provider’s or supplier’s Medicare, Medicaid, or CHIP enrollment if CMS determines that the affiliation poses an undue risk of fraud, waste, or abuse.
  • Different Name, Numerical Identifier, or Business Identity: CMS could deny or revoke a provider’s or supplier’s Medicare enrollment if the agency determines that the provider or supplier is currently rejected to participate in federal health care programs under a different name, numerical identifier, or business identity.

  • Abusive Ordering/Certifying: CMS could revoke a physician’s or eligible professional’s Medicare enrollment if he or she has a pattern or practice of ordering, certifying, referring, or prescribing Medicare Part A or B services, items, or drugs that is abusive, represents a threat to the health and safety of Medicare beneficiaries, or otherwise fails to meet Medicare requirements.
  • Increasing Medicare Program Re-enrollment Bars: CMS could raise the existing maximum amount of time that a provider can be kept out of the Medicare program by: 1) raising the existing maximum re-enrollment bar from three years to 10 years; 2) Allowing 3+ years to the provider’s or supplier’s re-enrollment bar if the provider attempts to re-enroll in Medicare under a different name, numerical identifier, or business identity; or 3) Imposing a maximum 20-year re-enrollment bar if the provider or supplier is revoked from the Medicare program for a second time.
  • Other Public Program Termination: CMS could deny or revoke a provider’s or supplier’s Medicare enrollment if: 1) the provider or supplier is currently terminated from participation in a particular Medicaid program or any other federal health care program under any of its current or former names, numerical identifiers, or business identities; or 2) the provider’s or supplier’s license is revoked in a state other than the state where the provider or supplier is currently enrolling or enrolled.

  • Expansion of Ordering/Certifying Requirements: CMS could require that physicians and eligible professionals who order, certify, refer, or prescribe any Part A or B service, item, or drug must be enrolled in or validly opted-out of Medicare.  
Go to the CMS Website to review the Factsheet

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