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New CMS Rule: Program Integrity Enhancements to the Provider Enrollment Process

The Centers for Medicare & Medicaid Services (CMS) recently announced a final rule entitled “Program Integrity Enhancements to the Provider Enrollment Process.” The new rule, which will go into effect on November 4, 2019, requires Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) providers and suppliers to disclose any current or previous direct or indirect “affiliations” (as specifically defined by CMS) with another provider or supplier that:

  1. has uncollected debt
  2. has been, or is, subject to a payment suspension under a federal health care program
  3. has been, or is, excluded by the Office of Inspector General (OIG) from Medicare, Medicaid, or CHIP
  4. had its Medicare, Medicaid, or CHIP billing privileges denied or revoked

Under the new rule, CMS will have additional authority to deny or revoke a provider’s Medicare enrollment if the Secretary determines that an affiliation poses an undue risk of fraud, waste, or abuse. CMS may deny or revoke a provider’s Medicare enrollment if a provider or supplier:

  1. is currently revoked under a different name, a numerical identifier, or business identity and the re-enrollment bar period has not expired
  2. billed for services performed at, or items furnished from a non-compliant location
  3. has a pattern or practice of ordering, certifying, referring, or prescribing services, items, or drugs that are abusive, represents a threat to patient safety, or fails to meet Medicare requirements
  4. submitted false or misleading information on the enrollment application
  5. has an existing debt that CMS refers to the U.S. Department of Treasury

The new rule also increases the maximum re-enrollment bar from three to ten years for a provider or supplier whose billing privileges have been revoked.

Medicare, Medicaid, and CHIP providers and suppliers should implement robust internal compliance plans to minimize the risk of triggering a denial or revocation of enrollment. For questions regarding the Program Integrity Enhancements to the Provider Enrollment Process or appeals of denials or revocations of provider enrollment, contact Frier Levitt today to speak to an attorney.