Volume 23.03
CMS’s increasing focus on provider integrity continues as they have proposed numerous Medicare enrollment changes impacting healthcare providers of all types. The proposed rule includes, but is not limited to, the following:
Reporting Changes in Practice Location – CMS is proposing to require practice location changes, additions, and deletions be reported within 30 days for all provider types. A change of practice location includes adding a new location or deleting an existing one. Currently, changes in practice location are to be reported within ninety (90) days of the change.
Reporting Misdemeanors §424.535(a)(16)(i) would be revised to include misdemeanors. CMS will have the authority to revoke a provider’s or supplier’s enrollment if they, or any owner, managing employee or organization, officer, or director has been convicted of a misdemeanor under Federal or State law within the previous ten (10) years. Likewise, an enrollment application may be denied due to misdemeanors (§424.530 to be revised).
Civil Judgements Under the False Claims Act (“FCA”) – §424.535(a)(15) would be added 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, the term “civil judgment” would not include FCA settlement agreements.
Failure to Repay a Debt – 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. In determining whether a revocation is appropriate related to a provider’s debt, CMS proposes to 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, at the appropriate appeal level, has not expired. The term “existing debt” would be changed to “failure to repay a debt”.
Effective Date for Revocations – The proposed rule identifies specific dates for provider enrollment revocations.
The Physician Payment Rule is available here.
WHAT ABOUT IMPLEMENTATION AND ENFORCEMENT OF THE 2019 PROGRAM INTEGRITY RULE
In 2019, CMS issued the final rule, “Provider Integrity Enhancements to the Provider Enrollment Process.” This rule created several new revocation and denial authorities to bolster CMS’ efforts to stop waste, fraud, and abuse. Importantly, a new “affiliations” authority in the rule allows CMS to identify individuals and organizations that pose an undue risk of fraud, waste or abuse based on their relationships with other previously sanctioned entities. For example, a currently enrolled or newly enrolling organization that has an owner/managing employee who is “affiliated” with another previously revoked organization can be denied enrollment in Medicare, Medicaid, and CHIP or, if already enrolled, can have its enrollment revoked because of the problematic affiliation. To date, we have not seen any significant efforts relating to the implementation of this rule; however, the increased focus on provider integrity should cause providers to refamiliarize themselves with the provisions of the rule. Further summary information can be obtained here.