CMS Publishes Proposal to Implement Affordable Care Act Provider and Supplier Fraud and Abuse Screening Requirements


Authorized by the Affordable Care Act of 2010, CMS issued proposed regulations that will implement provisions to screen providers based on the level of risk for fraud, require payment of fees for enrollment and revalidation of institutional providers, and allow for temporary moratoria on new provider enrollment and suspension of payments to providers.

The Centers for Medicare and Medicaid Services (CMS) published in the September 23, 2010, Federal Register proposed regulations (Proposal) that will implement provisions of the Affordable Care Act of 2010 requiring that CMS establish categories of risk for fraud and waste to the Medicare and Medicaid programs, and levels of screening of providers (mainly health care entities that furnish services primarily payable under Medicare Part A) and suppliers (mainly health care entities that furnish services primarily payable under Part B) corresponding to the level of risk associated with that category of provider. (While there are legal distinctions between “providers” and “suppliers,” to avoid duplication of terms, the single term “provider” is used to refer to both.) Institutional providers, with the exception of Part B medical groups or clinics and physician and non-physician practitioners, will be subject to an application fee beginning on March 23, 2011. Eligible professionals, such as physicians and nurse practitioners, are excluded from paying this fee. Revalidating institutional providers will be subject to the fee starting after March 23, 2011. The Proposal contains provisions for temporary moratoria on enrollment of Medicare, Medicaid and CHIP providers in six-month increments in situations where CMS identifies a trend that appears to be associated with a high risk of fraud, waste or abuse, including where a state has imposed a moratorium on enrollment in a particular geographic area or on a particular provider or supplier type. As authorized by the Affordable Care Act, the Proposal will implement provisions for suspension of payment to a provider pending an investigation of a credible allegation of fraud unless CMS determines that there is good cause not to suspend payments. The Proposal also solicits comments on requirements for compliance programs by Medicare and Medicaid certified nursing facilities, and for providers. CMS is accepting comments on the proposed screening and enrollment regulations until November 16, 2010.

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