Blog: Final Rule Issued by CMS re: New Enforcement Authorities to Reduce Criminal Behavior in Medicare, Medicaid and CHIP

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The Centers for Medicare & Medicaid Services (CMS) issued late last week a final rule with comment period titled, Program Integrity Enhancements to the Provider Enrollment Process (CMS-6058-FC) (Final Rule). The Final Rule is intended to proactively prevent fraud and abuse against the Federal health care programs, including Medicare, Medicaid and the Children’s Health Insurance Programs (FHCP), by providers and suppliers. The Final Rule takes effect on November 4, 2019 and provides CMS the authority to revoke and/or deny enrollment to providers and suppliers who are directly or indirectly affiliated, now or in the past, with certain organizations, owners or managing employees. Specifically, the Final Rule requires applicants to disclose information regarding such affiliations with individuals or entities who: (1) have been excluded, terminated or suspended from participation in FHCPs; (2) have had billing privileges in FHCPs denied or revoked; (3) have been subjected to FHCP payments suspension; or (4) have uncollected debt.

The Final Rule also allows CMS to revoke and/or deny provider and supplier enrollment under certain circumstances, including if the provider or supplier: (1) is currently revoked and using different names or numbers to participate in FHCPs; (2) is billing for items or services provided at locations out of compliance with FHCP billing requirements; (3) is engaging in abusive practices, fails to satisfy FHCP requirements or is a threat to patients health and safety; or (4) has an outstanding debt with CMS referred to the Department of Treasury.

Applicants who submit false or misleading information in initial applications will be prohibited from reapplying for up to three years, and any provider or supplier whose enrollment has been revoked once will not be permitted to reenroll for up to ten years. An applicant whose enrollment has been revoked twice will not be permitted to reenroll for up to 20 years.

Comments to the Final Rule must be received by 5:00 PM EST on November 4, 2019. All providers and suppliers should review carefully the Final Rule and consider submitting comments. Further, providers and suppliers should consider implementing enhancements to the background diligence process and review the effectiveness of certain key compliance areas.

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DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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