CMS proposes program integrity enhancements to provider enrollment

The Centers for Medicare and Medicaid Services (CMS) has issued a proposed rule implementing additional provisions of the Affordable Care Act designed to ensure that questionable providers and suppliers are kept out of or removed from the Medicare program. If finalized, these regulations would enable CMS to remove or prevent the enrollment of entities and individuals that try to circumvent Medicare enrollment requirements through name/identify changes and through complex inter-provider relationships.  The proposed rule would also respond to other program integrity issues, including instances where providers and suppliers avoid paying Medicare debts by re-enrolling as a different entity.

Major provisions of the proposed rule include:

• A requirement for enrollees to report certain questionable affiliations and the corresponding potential for CMS to deny or revoke federal health care program enrollment if the agency determines an affiliation poses un undue risk of fraud, waste or abuse;
• The ability for CMS to revoke a physician or eligible professional’s Medicare enrollment if he/she has a pattern or practice of abusive ordering/certifying of Medicare Part A or B services;
• Increasing Medicare program re-enrollment bars from three years to 10 years, with a maximum 20-year re-enrollment bar for providers or suppliers with two enrollment revocations;
• The ability for CMS to deny or revoke Medicare enrollment based on termination from other public programs; and
• Expansion of ordering/certifying requirements for physicians and eligible professionals who order, certify, refer or prescribe any Part A or B service, item, or drug.
• According to CMS, these program integrity enhancements would produce substantial financial and other gains for the Medicare program. For instance, CMS reports a total estimated cost savings of $2.4 billion for Medicare revoked providers from 2011 to 2015, $1.4 billion of which stems from Affordable Care Act provisions.

The proposed rule is scheduled for publication in the Federal Register on March 1, 2016.