CMS Issues Final Rule to Reduce Criminal Behavior in Medicare, Medicaid, and CHIP

September 2019 ~

CMS, on September 5, issued a new final rule, known as the Program Integrity Enhancements to the Provider Enrollment Process, that will expand the agency’s power to remove providers from the programs if found to have a previous affiliation with a banned organization, even if the provider itself has not been directly hit with a federal investigation.

According to CMS, the new rule builds on the agency’s previous efforts to protect beneficiaries and taxpayer dollars while limiting the burden on the provider partners.

The new rule creates several new revocation and denial authorities to bolster CMS’ efforts to stop waste, fraud, and abuse, according to the CMS Press Release. The agency notes, in the release, that a new “affiliations” authority in the rule will allow CMS to identify individuals and organizations that pose an undue risk of fraud, waste or abuse based on their relationships with other previously sanctioned entities.

“For too many years, we have played an expensive and inefficient game of ‘whack-a-mole’ with criminals – going after them one at a time — as they steal from our programs. These fraudsters temporarily disappear into complex, hard-to-track webs of criminal entities, and then re-emerge under different corporate names. These criminals engage in the same behaviors again and again,” stated CMS Administrator Seema Verma.  “Now, for the first time, we have tools to stop criminals before they can steal from taxpayers. This is CMS hardening the target for criminals and locking the door to the vault. If you’re a bad actor you can never get into the program, and you can’t steal from it.”

The Program Integrity Enhancements to the Provider Enrollment Process rule also includes other authorities that will effectively improve CMS’ fraud-fighting capabilities. Similar to the affiliations component, these authorities provide a basis for administrative action to revoke or deny, as applicable, Medicare enrollment if:

  1. 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);
  2. A provider or supplier bills for services/items from non-compliant locations;
  3. 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
  4. A provider or supplier has an outstanding debt to CMS from an overpayment that was referred to the Treasury Department.

Also under the new rule, CMS will be given the ability to prevent applicants from enrolling in the program for up to three years if a provider or supplier is found to have submitted false or misleading information in its initial enrollment application. Additionally, according to the release, the new rule expands the re-enrollment bar that prevents fraudulent or otherwise problematic providers from re-entering the Medicare program. With this change, the agency 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. If a provider or supplier is revoked from Medicare for a second time, CMS can now block that provider or supplier from re-entering the program for up to 20 years.

The agency states these new restrictions will ensure that the only providers and suppliers that will face additional burdens are “bad actors” (i.e. those who have real and demonstrable histories of conduct and relationships that pose an undue risk to taxpayers, patients, and program beneficiaries), according to CMS.

“Every dollar that is stolen from federal programs is a dollar that will never contribute to paying for an item or service for seniors and eligible people who need them,” Administrator Verma commented.

Comments to the Final Rule must be received by 5:00 PM EST on the rule’s effective date, November 4, 2019.

Source(s): CMS Press Release; Federal Register; Modern Healthcare; American Physical Therapy Association; National Association for Home Care & Hospice; Lexology; JD Supra; Skilled Nursing News; Healthcare DIVE;