By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law
On September 5, 2019, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that strengthens the ability to stop fraud and abuse before it happens. The “Program Integrity Enhancements to the Provider Enrollment Process” goes into effect on November 4, 2019, and will help keep untrustworthy providers out of federal health insurance. The new affiliations provision will allow CMS to identify individuals and organizations that pose an undue risk of fraud, waste or abuse and repeat offenders.
Details on the Rule.
The final rule, (CMS-6058-FC), creates several new revocation and denial authorities to enhance CMS’ efforts to stop fraud and abuse.
Similar to the affiliations component, these authorities provide a basis for administrative action to revoke or deny, as applicable, Medicare enrollment if:
• A provider or supplier circumvents program rules by coming back into the program, or attempting to come back in, under a different name (e.g. the provider attempts to “reinvent” itself);
• A provider or supplier bills for services/items from non-compliant locations;
• A provider or supplier exhibits a pattern or practice of abusive ordering or certifying of Medicare Part A or Part B items, services or drugs; or
• A provider or supplier has an outstanding debt to CMS from an overpayment that was referred to the Treasury Department.
Additionally, the rule gives CMS the ability to prevent applicants from enrolling in the program for up to three years if found to have submitted false or misleading information in its initial enrollment application.
Furthermore, the new rule expands the re-enrollment bar that prevents fraudulent or otherwise problematic providers from re-entering the Medicare program. CMS can now block providers and suppliers who are revoked from re-entering the Medicare program for up to 10 years. Previously, revoked providers could only be prevented from re-enrolling for up to three years.
Additionally, if a healthcare provider or supplier is revoked from Medicare for a second time, CMS can now block him/her from re-entering the program for up to 20 years. These new authorities and restrictions are effective on November 4, 2019.
For more information, click here to view the final rule with comment.
To learn more about the Medicare enrollment application process, click here to read my prior blog.
Don’t Wait Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.
The lawyers of The Health Law Firm routinely represent physicians, medical groups, clinics, pharmacies, durable medical equipment (DME) suppliers, home health agencies, nursing homes and other healthcare providers in Medicare and Medicaid investigations, audits and recovery actions. They also represent them in preparing and submitting corrective action plans (CAPs), requests for reconsideration, and appeal hearings, including Medicare administrative hearings before an administrative law judge. Attorneys of The Health Law Firm represent health providers in actions initiated by the Medicaid Fraud Control Units (MFCUs), in False Claims Act cases, in actions initiated by the state to exclude or terminate from the Medicaid Program or by the HHS OIG to exclude from the Medicare Program.
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Kacik, Alex. “CMS targets healthcare providers’ affiliates in new rule.” Modern Healthcare. (September 5, 2019). Web.
“CMS Announces New Enforcement Authorities to Reduce Criminal Behavior in Medicare, Medicaid, and CHIP.” Orlando Medical News. (September 5, 2019). Web.
“CMS takes action to keep fraudsters out of Medicare and Medicaid.” CMS.gov. (September 5, 2019). Web.
About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.
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