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Volume 23.06

The Centers for Medicare and Medicaid Services (“CMS”) has finalized the CY 2024 Medicare Physician Fee Schedule rule.  Many enrollment-related provisions were included in the proposed rule.  The Health Group, LLC discussed the proposed rule at its Hospice Financial and Administrative Management Conference last week.  The following summarizes key enrollment provisions that were finalized:

  • Adds § 424.535(a)(15) permitting CMS to revoke the enrollment of a provider or supplier if the provider or supplier, or any owner, managing employee or organization, officer, or director has had a civil judgment under the False Claims Act (FCA) imposed against them within the previous 10 years. However, FCA settlement agreements are not considered to be a civil judgment.
  • Adds a new paragraph (a)(23) to § 424.535 that would permit CMS to revoke the enrollment of independent diagnostic testing facilities (IDTF’s), durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) supplier’s, opioid treatment programs (OTP’s), home infusion therapy (HIT) suppliers, or Medicare diabetes prevention programs (MDPP’s) based on a violation of any standard or condition of enrollment.
  • Under § 424.535(a)(17), CMS may revoke enrollment if the provider or supplier has an existing debt that CMS appropriately refers to the United States Department of Treasury for collection. In determining whether a revocation is appropriate related to a provider’s debt, CMS will exclude from paragraph (a)(17)(i) those cases where: (1) the provider’s or supplier’s Medicare debt has been discharged by a bankruptcy court; or (2) the administrative appeals process concerning the debt has not been exhausted, or the timeline for filing such an appeal has not expired. The term existing debt would be changed to “failure to repay a debt”.

The rule also modifies the effective date of revocations as follows:

  • Revocations based on the surrender of a state license will be the date of the license surrender.
  • Revocations based on the termination from a federal health care program, other than Medicare, would be the effective date of the termination.
  • In the case of a felony conviction of an individual or entity, the revocation would be the date of the conviction.

CMS established a new enrollment status referred to as a “Stay of Enrollment”.  The stay of enrollment is a preliminary, interim status to any subsequent deactivation or revocation that represents, in a sense, a “pause” in enrollment, during which the provider or supplier would remain enrolled in Medicare.  During the period of any stay the provider or supplier remains enrolled in Medicare, but claims submitted by the provider or supplier with dates of service within the stay period will be rejected rather than denied as was proposed.  Claims submitted by the provider or supplier with dates of service within the stay period are eligible for payment and may be resubmitted by the provider or supplier if they have come into compliance within the 60 days stay period.  The stay will last no longer than 60 days.

The rule also requires providers to report practice location changes, additions, or deletions within thirty (30) days of the event.

CMS did not finalize its proposal to include misdemeanors as a potential reason for enrollment revocations and application denials.

The final rule is available here.  More information will be provided upon further assessment of the rule.