Last Friday, CMS announced a six month extension of a temporary moratorium preventing new ambulance suppliers and home health agencies in six states from enrolling in Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP).

The moratorium impacts providers in the metropolitan areas of Chicago, Miami, Detroit, Dallas, Houston, and Philadelphia.

Federal regulations established under the Affordable Care Act authorize CMS to “impose a temporary moratorium on newly enrolling Medicare providers and suppliers if it determines that there is a significant potential for fraud, waste, or abuse with respect to a particular provider or supplier type or particular geographic locations.”

The first moratorium was implemented in July of 2013 and was extended and expanded by CMS in February of 2014 and again in August of 2014.

CMS decisions to impose or extend moratoria such as this one are not subject to judicial review.  Affected providers and suppliers have recourse through the administrative appeal process; however, the scope of the appeal process is limited to assessing whether the temporary moratorium applies to the provider or supplier in question.

CMS notes that its decision to extend the moratorium was made in consultation with the HHS-Office of Inspector General and the DOJ and was based on extensive data analysis of factors identified as strong indicators of risk, such as a disproportionate number of providers and  suppliers relative to the population of eligible beneficiaries, a sharp increase in the number of providers and supplies applying for Medicare and Medicaid enrollment, and extremely high utilization in certain areas.

In explaining its action, the Agency noted that: “The circumstances warranting the imposition of the moratoria have not yet abated, and CMS has determined that the moratoria are still needed as we monitor the indicators and continue with administrative actions such as payment suspensions and revocations of provider/supplier numbers.”

The moratorium is part of the government’s effort to transition from a “pay and chase” model for combating fraud to a model that is more focused on fraud prevention.

 

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*Savannah Wiseman is admitted only in Texas. Practice supervised by principals of the firm admitted in the District of Columbia.

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