Volume 26.05
The Centers for Medicare & Medicaid Services (“CMS”) finalized changes intended to effect recovery of Medicare payments from noncompliant providers and suppliers, as well as prevent high-risk providers from entering or remaining in the Medicare program. These changes are included in the Calendar Year 2027 Home Health Prospective Payment System Final Rule (“final rule”). Some of the most notable provisions include:
Revocation Date – Most significantly, CMS can make Medicare enrollment revocations effective as of the date noncompliance began, thereby, allowing payments to be recovered from that date forward. This change applies to all Medicare provider and supplier types. Under current rules, a revocation is, generally, effective thirty (30) days after CMS or its contractor mails the revocation notice.
Failure to Report – It is important that providers recognize that failing to timely report any changes in enrollment information – as opposed to only changes of ownership, adverse legal actions, and practice locations – will now be retroactive to the day after the change was due to be reported. Revoked providers have fifteen calendar days from the date of the revocation letter to submit claims for items or services furnished before the revocation date. Special rules apply to home health agencies.
False and Misleading Information – The final rule provides for denial and revocation based on false or misleading information on, or associated with, any CMS or Medicare enrollment-related forms or documentation. This extends beyond the enrollment application itself.
Geographical Area – CMS finalized the ability to revoke a provider’s enrollment if CMS deems the enrollment to present a high risk of fraud, waste, or abuse due to the provider’s location within a limited geographical area that has an excessive number of providers and suppliers.
Misdemeanor Convictions – CMS finalized a new basis for denial and revocation applicable to instances where the provider, an owner, managing employee, organization, officer, or director was convicted within the preceding ten (10) years of a federal or state misdemeanor related to sexual assault or financial misconduct that CMS determines detrimental to the best interest of the Medicare program or its beneficiaries.
Common Location – A new denial ground is created for providers whose practice location is in the same suite or office as another provider whose Medicare enrollment has been revoked or denied.
Hospice Medical Directors and Administrators – CMS has finalized a new hospice-specific enrollment denial. A hospice’s enrollment application may be denied if the medical director or administrator serves other hospices, or if the medical director or administrator is located at such a distance as to make performance unrealistic. This only relates to enrollments and is not a reason for revocation.
Affiliations – CMS may deny or revoke enrollment if a provider is affiliated with another provider that has a disclosable event which poses an undue risk of fraud, waste, or abuse.
Managing Employees – CMS has revised managing employees who are required to be reported to include medical directors, clinical directors, department heads, supervising physicians, nursing directors, alternate administrators, and all clinical personnel meeting the published definition of a managing employee. Changes in managing employees must continue to be reported within thirty (30) days.
Many more requirements related to integrity have been modified, expanded, or added. These deal with operational/practice locations, signage, hospice reactivations, and the preclusion list.
The Health Group, LLC, will be reviewing the final rule in detail over the next few weeks and will be reporting on many specifics. The final rule is available here.
THE HEALTH GROUP PROFESSIONALS TO ATTEND NATIONAL PROVIDER ENROLLMENT CONFERENCE
Several professionals at The Health Group, LLC, will be attending the upcoming National Provider Enrollment Conference. Representatives for CMS as well as all Medicare Administrative Contractors (“MACs”) will be in attendance. We hope to receive clarification of many outstanding enrollment issues, as well as the newly imposed requirements. If you have any questions regarding existing or newly established requirements, do not hesitate to contact us at contact@healthgroup.com.