By Nadine E. Roddy, J.D.
The rule addresses various program integrity issues and vulnerabilities by enabling CMS to take action against unqualified and potentially fraudulent entities and individuals.
Medicare, Medicaid, and Children's Health Insurance Program (CHIP) providers and suppliers must disclose certain current and previous affiliations with other providers and suppliers under a final rule with comment period issued by CMS. The rule also provides CMS with additional authority to deny or revoke a provider's or supplier's Medicare enrollment in specified circumstances. The comment period ends on November 4, 2019, at which time the final rule will take effect (Final rule, 84 FR 47794, September 10, 2019).
CMS has published the final rule to implement a provision of the Soc. Sec. Act requiring Medicare, Medicaid, and Children's Health Insurance Program (CHIP) providers and suppliers to disclose any current or previous direct or indirect affiliation with a provider or supplier that:
- has uncollected debt;
- has been or is subject to a payment suspension under a federal health care program;
- has been or is excluded by the Office of Inspector General (OIG) from Medicare, Medicaid, or CHIP; or
- has had its Medicare, Medicaid, or CHIP billing privileges denied or revoked.
This provision permits CMS to deny enrollment based on such affiliations when it determines that the affiliation poses an undue risk of fraud, waste, or abuse. Definitions for the terms "affiliation," "disclosable event," "uncollected debt," and "undue risk" are set forth.
The final rule also grants CMS the authority to do the following:
- Deny or revoke a provider's or supplier's Medicare enrollment if CMS determines that the provider or supplier is currently revoked under a different name, numerical identifier, or business identity, and the applicable reenrollment bar period has not expired.
- Revoke a provider's or supplier's Medicare enrollment—including all of the provider's or supplier's practice locations, regardless of whether they are part of the same enrollment—if the provider or supplier billed for services performed at, or items furnished from, a location that it knew or should reasonably have known did not comply with Medicare enrollment requirements.
- Increase the maximum reenrollment bar from three to ten years, with certain exceptions.
- Prohibit a provider or supplier from enrolling in the Medicare program for up to three years if its enrollment application is denied because the provider or supplier submitted false or misleading information on or with (or omitted information from) its application in order to gain enrollment in the Medicare program.
- Revoke a provider's or supplier's Medicare enrollment if the provider or supplier has an existing debt that CMS refers to the Department of Treasury.
The principal legal authorities for the Final rule include Section 2107(e)(1) of the Soc. Sec. Act, as amended by Section 6401(c) of the Patient Protection and Affordable Care Act, which makes the requirements of Section 1902(kk) of the Soc. Sec. Act, including the disclosure requirements, applicable to CHIP.
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