CMS aims to combat criminal behavior through enrollment process

October 29, 2019

Alert

The Centers for Medicare & Medicaid Services (CMS) recently issued a final rule providing new enforcement authorities to reduce criminal behavior in its programs. The goal of the final rule - Program Integrity Enhancements to the Provider Enrollment Process - is to stop fraud before it happens by keeping “unscrupulous providers” out of the federal healthcare programs. The rule creates new revocation and denial authorities in an effort to stop waste, fraud, and abuse.

A key authority in the rule deals with affiliations. It puts a huge burden on all providers to maintain information on any affiliations, past, present or future, with excluded individuals or entities. The final rule imposes a five-year look back on affiliations, which means that a provider will need to obtain and maintain all required disclosable events from each and every affiliation and provide that information to CMS for review. CMS will take this information and review it to determine if an individual or entity poses an undue risk of fraud waste or abuse based upon their relationships with previously sanctioned entities. Additionally, the rule allows CMS to revoke or deny enrollment in the following circumstances:

A provider or supplier has an outstanding debt to CMS from an overpayment.
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.

The rule is effective November 4, 2019. However, due to the staggering burden on providers to collect and maintain this information, CMS has decided to take a phased-in approach to implementation. For the initial phase, CMS will request affiliation disclosure from targeted providers. If a provider is served with one of these requests, it must fully comply with the requested disclosure of applicable affiliations. The rule states that sub-regulatory guidance will be issued to clarify expectations under this final rule.

In the meantime, if you receive a request from CMS regarding your affiliations or would like additional information please contact the attorney below.

Over the past 24 months, the U.S. Department of Health and Human Services Office for Civil Rights has brought notable enforcement efforts against several non-profit covered entities and business associates, resulting in instances of six and seven-figure penalties against providers across the county for incidents involving breaches of protected health information.

A new amendment to New York state law, which would have required all healthcare providers to obtain separate consents from patients for treatment and payment is on hold until further guidance is released, according to the New York Department of Health.

On November 1, 2024, the Centers for Medicare & Medicaid Services issued the Medicare Physician Fee Schedule 2025 final rule, which establishes new advanced primary care management billing codes that will expand opportunities for physician practices, federally qualified health centers, rural health clinics and other health care providers to get paid for services provided by clinical staff under the direction of a physician, nurse practitioner or physician assistant beginning January 1, 2025.

CMS aims to combat criminal behavior through enrollment process

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