Proposed MPFS Seeks Changes to Medicare Billing Privileges Rules

September 2019 ~

CMS’ proposed 2020 Medicare Physician Fee Schedule includes a statement that calls for applying Medicare enrollment approval and revocation rules for opioid treatment programs to all physicians and other eligible professionals. The proposal would allow CMS to revoke Medicare billing privileges for physicians, advanced practice nurses and others for a variety of reasons.

Sections 424.530(a)(15) and 424.535(a)(22) of the proposal would apply to physicians and other eligible professionals in opioid treatment programs (OTP) and non-OTP settings. Revocation or denial action could be taken against physicians and other eligible professionals in solo practice or who are part of a group or any other provider or supplier type.”).

If finalized, the rule would allow CMS to revoke the Medicare billing privileges of any physician who has “been subject to prior action from a state oversight board, federal or state health care program, Independent Review Organization (IRO) determination(s), or any other equivalent governmental body or program that oversees, regulates, or administers the provision of healthcare with underlying facts reflecting improper physician or other eligible professional conduct that led to patient harm.”

In the proposed rule, CMS expressed concerned that state licensing boards may choose to “impose a relatively minor sanction on a physician or other eligible professional for conduct that we deem more serious.” CMS announced that it, “rather than state boards, is ultimately responsible for the . . . protection of its beneficiaries.” CMS hopes this change will empower the agency with the “discretion to . . . determine whether, in the agency’s view, the physician’s or other eligible professional’s conduct warrants revocation or denial.”

According to CMS, the agency will consider several factors when determining whether an action constitutes patient harm:

  • License restriction(s) pertaining to certain procedures or practices;
  • Required compliance appearances before State oversight board members;
  • Required participation in rehabilitation or mental/behavioral health programs;
  • Required abstinence from drugs or alcohol and random drug testing;
  • Administrative/monetary penalties;
  • Formal reprimand(s);
  • If applicable, the nature of the IRO determination(s); or
  • Any other information that CMS deems relevant to its determination.

The agency states that it will not automatically revoke billing privileges or deny enrollment based on “very modest sanction[s],” and noted it would “only take such a measure after the most careful consideration” of the “nature of the patient harm,” “the nature of the physician’s or other eligible professional’s conduct” and the “number of type(s) of sanctions or disciplinary actions” imposed.

Comments on the proposed rule are due by 5:00 p.m. on September 27, 2019.

Source(s): Policy & Medicine; Becker’s Hospital Review; Policy & Medicine; National Law Review; JD Supra; Baker Donelson; American Hospital Association; IntelliSoft Group;