CMS Program Integrity Changes

CMS Announces Program Integrity Enhancements to the Provider Enrollment Process

CMS announced a proposed rule for implementing additional provider enrollment provisions of the Affordable Care Act to help identify entities and individuals who pose risks to the Medicare program.  The provisions allow for identified high risks applicants to be kept out of the program or removed from Medicare for an extended period.

medicare

Proposed Rule Summary

The proposed rule attempts to identify any provider or supplier enrolling in the Medicare program who may have been affiliated with an organization or provider involved with Medicare fraud, outstanding Medicare repayment debt, exclusion from the program, or denial of an initial enrollment application.  CMS would put the burden on the enrolling provider of attesting during the application process (or revalidation process) about all owners and managing employees previous involvement in such scenarios within the previous 5 years.

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.

Definition of Affiliation

  • A 5 percent or greater direct or indirect ownership interest that an individual or entity has in another organization.
  • A general or limited partnership interest (regardless of the percentage) that an individual or entity has in another organization.
  • An interest in which an individual or entity exercises operational or managerial control over or directly or indirectly conducts the day-to-day operations of another organization (including sole proprietorship’s), either under contract or through some other arrangement, regardless of whether or not the managing individual or entity is a W-2 employee of the organization.
  • An interest in which an individual is acting as an officer or director of a corporation.
  • Any reassignment relationship

Disclosable Events

  1. A provider or supplier that is submitting an initial or revalidating Form CMS–855 application must disclose whether it or any of Medicare Appits owning or managing employees or organizations (consistent with the terms ‘‘owner’’ and ‘‘managing employee’’ as defined in § 424.502) has or, within the previous 5 years, has had an affiliation with a currently or formerly enrolled Medicare, Medicaid or CHIP provider or supplier that currently has an uncollected debt to Medicare, Medicaid or CHIP, regardless of—(1) the amount of the debt; (2) whether the debt is currently being repaid (for example, as part of a repayment plan); or (3) whether the debt is currently being appealed.
  2. Has been or is subject to a payment suspension under a federal health care program (as that term is defined in section 1128B(f) of the Act), regardless of when the payment suspension occurred or was imposed;
  3. Has been or is excluded from participation in Medicare, Medicaid or CHIP, regardless of whether the exclusion is currently being appealed or when the exclusion occurred or was imposed (although section 1866(j)(5) of the Act states ‘‘has been excluded,’’ we believe it is appropriate to clarify that a current exclusion is also a disclosable event); or
  4. Has had its Medicare, Medicaid or CHIP enrollment denied, revoked or terminated, regardless of—(1) the reason for the denial, revocation or termination; (2) whether the denial, revocation or termination is currently being appealed; or (3) when the denial, revocation or termination occurred or was imposed. For purposes of § 424.519 only, and as stated in proposed paragraph (a), the terms ‘‘revoked,’’ ‘‘revocation,’’ ‘‘terminated,’’ and ‘‘termination’’ would include situations where the affiliated provider or supplier voluntarily terminated its Medicare, Medicaid or CHIP enrollment to avoid a potential revocation or termination.

Impact On Providers

The level of record retention providers and suppliers must maintain would increase dramatically.  The responsibility for full disclosure will be the sole responsibility of the enrolling provider or supplier.  Imagine if you are starting a new medical group with five other partners.  During your enrollment process, you must record every disclosable event for all five partners within the past five years plus any events of your business management staff.  That means if one of the partners was working for another practice 4 years ago and the practice has unpaid Medicare overpayments, then you have to know and disclose that on your enrollment application.

The intent of these proposed changes are positive for protection of the Medicare program.  Many providers and suppliers have been found circumventing repayment obligations or program exclusion through name and identify changes as well as through elaborate, inter-provider relationships.  However, the proposed rule as written will place a massive burden on every provider enrolling in the Medicare program.

Providers and entities everywhere should be preparing for some level of these regulations to eventually be put in place.  Maintain accurate enrollment records throughout your career and know what is happening in your practice.  Be certain to carefully screen your managing employees, such as office managers, for exclusion from the Medicare program.  You are personally responsible for any Medicare enrollment application that is submitted with your name on it, so make sure you are entirely accurate on every enrollment application submitted.

Credentialing Needs

If your organization needs assistance with understanding the Medicare enrollment process or other insurance credentialing matters, contact National Credentialing Solutions at (423) 443-3840 or visit them online at NationalCredentialing.com