Effective Nov. 4th, 2019, the Centers for Medicare & Medicaid Services (CMS) has additional authority to deny or revoke a provider’s or supplier’s Medicare enrollment in certain specified circumstances. In an effort to maintain integrity and prevent fraud, this new Medicare enrollment final rule will eventually require all providers and suppliers to report even modest partnership/managerial relationships with other entities whose debts, exclusions, revocations and suspensions may affect you.
The rule would allow providers and suppliers to be kicked out if the U.S. Department of Health and Human Services (HHS) thinks this secondhand relationship “poses an undue risk of fraud, waste or abuse.”
The rule, first proposed in March 2016 and finalized Sept. 10, mandates that CMS conduct “research and analysis” to determine whether providers and suppliers that are enrolled in federal health care programs have affiliations with any individual or entity “that has uncollected debt; has been or is subject to a payment suspension under a federal health care program; has been excluded from Medicare, Medicaid or CHIP; or has had its Medicare, Medicaid or CHIP billing privileges denied or revoked.”
If it finds that type of affiliation, CMS may request that the enrollee disclose any other such affiliations. The federal Medicare agency defines an affiliation as “a 5% or greater direct or indirect ownership interest,” or “a general or limited partnership interest (regardless of the percentage) that an individual or entity has in another organization,” as well as an operational or managerial interest.
In the future, CMS-855 enrollment application forms will be updated to collect this data, and providers and suppliers will be required to disclose it when they revalidate their enrollments.
Farther reaching and greater restrictions
CMS also is authorized to bar providers and suppliers from enrollment for three years for supplying false or incomplete information and may ban some providers for up to 10 years if their behavior “could prove so harmful to Medicare, its beneficiaries and/or the trust funds that a very lengthy bar from Medicare is warranted.”
CMS claims these new powers and restrictions will save the government $47.4 billion over 10 years.
How Medicare will evaluate
During its Sept. 18 home health, hospice and durable medical equipment (DME) open door forum, CMS gave the following example: John Smith was the owner at Home Health Agency #1 (HHA1), which was revoked from Medicare because of improper billing. CMS learns Smith was also the owner of Home Health Agency #2 (HHA2), which means an affiliation exists.
In this scenario, Medicare would evaluate the affiliation at HHA2 and determine whether there is a risk of fraud, waste or abuse. If there is, HHA2 would also be revoked. If not, HHA2 would not be revoked based on affiliation.
But they won’t overreach…
“We plan to use this authority in a prudent and conscientious manner,” a CMS official said on the call.
CMS plans to focus only on “egregious behavior” when looking at affiliation situations.
Related link: View the Medicare, Medicaid, and CHIP; Program Integrity Enhancements to the Provider Enrollment Process at https://www.federalregister.gov/documents/2019/09/10/2019-19208/medicare-medicaid-and-childrens-health-insurance-programs-program-integrity-enhancements-to-the.