Proposed rule aims to prevent questionable providers, suppliers from entering Medicare program

Program Integrity Enhancements to the Provider Enrollment Process (CMS-6058-P)

This proposed rule is part of CMS’s ongoing and continuous effort to prevent questionable providers and suppliers from entering the Medicare program and enhance our ability to promptly identify and act on instances of improper behavior.

Summary: CMS is proposing new regulations that implement additional provider enrollment provisions of the Affordable Care Act to help make certain that entities and individuals who pose risks to the Medicare program and beneficiaries are kept out of or removed from Medicare for extended periods.

Background: These enhancements, if finalized, would allow CMS to take action to remove or prevent the enrollment of health care providers and suppliers that attempt to circumvent Medicare’s enrollment requirements through name and identity changes as well as through elaborate, inter-provider relationships.  The proposed provisions will also address other program integrity issues and vulnerabilities--such as cases where providers and suppliers avoid paying their Medicare debts by reenrolling as a different entity.

CMS now utilizes over 300 different state and federal databases to perform continuous license and background monitoring. We’ve conducted nearly 230,000 clinical location site visits and over 2,000 fingerprint checks since 2011. We also collaborate and communicate with states to ensure they have access to this important information and are making the same changes in their Medicaid systems.

Major Provisions:

  • Disclosure of Affiliations: Would require health care providers and suppliers to report affiliations with entities and individuals that: (1) currently have uncollected debt to Medicare, Medicaid, or 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 CMS determines that the provider or supplier is currently revoked under a different name, numerical identifier, or business identity.
  • Abusive Ordering/Certifying: Would allow CMS to 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: Would improve protection of the Medicare Trust Funds and program beneficiaries by:
    • Raising the existing maximum re-enrollment bar from three years to 10 years
    • Allowing CMS to add three more 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
    • Imposing a maximum 20-year reenrollment bar if the provider or supplier is being revoked from Medicare for the second time
  • Other Public Program Termination: Would permit CMS to 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 that in which the provider or supplier is enrolled or enrolling.
  • Expansion of Ordering/Certifying Requirements: Would permit CMS to 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.
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