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Volume 20.33

While healthcare providers deal with the COVID-19 PHE, preparing to deal with HHS reporting on the use of Provider Relief Funds, and many other ongoing issues, silently on May 22, 2020, CMS rolled out Transmittal 10146, which completely reorganized existing Chapter 15 of the Medicare Program Integrity Manual (MPIM), CMS 100-08.

These changes, effective July 24, 2020, implement the recent program integrity enhancements to the Medicare provider enrollment process, as well as other changes, and begin a transfer of some of the provider enrollment instructions from Chapter 15 to Chapter 10 of the MPIM.  Subsequently, Transmittal 10239 was released (July 28, 2020) to replace Transmittal 10146, with an implementation date of August 10, 2020.

These changes are largely the result of the Medicare, Medicaid, and Children’s Health Insurance Programs; Program Integrity Enhancements to the Provider Enrollment Process, final rule issued on September 10, 2019.  These changes largely deal with reporting affiliations and reviewable transactions.

Currently, providers and suppliers will not be required to disclose affiliations under § 424.519 unless CMS, after performing the research and analysis described earlier and determining that the provider or supplier may have at least one affiliation that includes any of the four disclosable events, specifically requests it to do so. We believe this will ease the burden on the provider community because CMS, rather than the provider or supplier, will be responsible for reviewing whether the disclosure requirement applies to the provider or supplier. However, should CMS find that it does apply, the provider or supplier in question must then report any and all affiliations that come within the scope of § 424.519, not merely the one(s) on which CMS made its determination. This could require the provider or supplier to conduct research to determine whether additional disclosable affiliations exist, which would then need to be reported to CMS.

However, once CMS updates its Form CMS-855 applications to include an affiliation disclosure section, a provider or supplier that may have at least one affiliation involving a disclosable event, as identified by CMS, will be required to report any and all affiliations upon initial enrollment or revalidation. It will be important for all providers and suppliers to begin investigating whether there are any disclosable affiliations by anyone affiliated with their organization.

“Affiliations” are defined in the CMS rule as:

  • A 5 percent or greater direct or indirect ownership interest that an individual or entity has in another organization.
  • A general or limited partnership interest (regardless of the percentage) that an individual or entity has in another organization.
  • An interest in which an individual or entity exercises operational or managerial control over, or directly or indirectly conducts, the day-to-day operations of another organization (including, for purposes of § 424.519 only, sole proprietorships), either under contract or through some other arrangement, regardless of whether or not the managing individual or entity is a W–2 employee of the organization.
  • An interest in which an individual is acting as an officer or director of a corporation.
  • Any reassignment relationship under § 424.80.

Medicare, Medicaid and CHIP providers will have to disclose any current or previous affiliation with an organization that has uncollected debt, has had a payment suspension under a federal healthcare program, has been excluded from those programs, or has had billing privileges denied or rescinded.

In addition, CMS will be able to revoke or deny Medicare enrollment if providers or suppliers attempt to get back into the program under a different name, bill for services from non-compliant locations, exhibit a fraudulent or wasteful pattern of ordering services or drugs, or have an outstanding debt to CMS from an overpayment that was referred to the Treasury Department. The agency may also prohibit an organization from participating in Medicare for up to 3 years if they falsify their enrollment application.

Healthcare providers cannot let continuing changes in Medicare enrollment go unattended.  Of course, much is dependent on changes made to the CMS Forms 855 addressing reporting affiliations at enrollment or revalidation.  We will continue to report any developments as they occur.