Volume 24.01
The Centers for Medicare & Medicaid Services (“CMS”) has continually been concerned regarding how to identify “bad actors”, their continued involvement with Medicare providers, and the appropriate response to inappropriate behavior by providers, whether such behavior is related to Medicare/Medicaid billings or other matters.
The efforts of CMS largely have focused on the identification of ownership, affiliations between owners and providers, and associating these owners and affiliates with activities that could cause the Medicare program to minimize or eliminate their involvement in the provision of Medicare covered services, and accordingly payment from the Medicare program.
In 2019, CMS adopted rules requiring Medicare, Medicaid, and Children’s Health Insurance Program (“CHIP”) providers and suppliers to disclose certain current and previous affiliations with other entities and provided CMS with the ability to revoke enrollment if such affiliation poses an undue risk of fraud and abuse. Since then, substantial ownership and other integrity-related rules have been finalized or proposed. Many of these are focused on specific providers, i.e. skilled nursing facilities, hospices, home health agencies, etc. Even so, CMS has been slow to implement the affiliation disclosures and related rules due to the complexity of the affiliation rules and the need to make substantial revisions to both CMS 855 Forms and PECOS. The CMS Form 855 was modified in 2023; however, the modifications were limited. CMS has been overwhelmed with the information to be gathered and assessed to fully implement the affiliation rules.
Other integrity related measures will be more easily implemented as they are better defined and are not as encompassing in the amount of information required.
CMS is not the only agency looking at ownership and other integrity issues. Effective January 1, 2024, many corporations and other organizations created under state laws, i.e. limited liability companies, are required to report beneficial ownership information to the U.S. Department of the Treasury. Additionally, Medicaid agencies, states, and others are looking at securing ownership information as well as creating their own integrity measures for purposes of addressing inappropriate parties and transactions.
It is significant that all healthcare providers commit sufficient resources, internal and/or external, to better ensure compliance with integrity initiatives of CMS and others. Our experience to date indicates that the current focus is on remedying any Medicare enrollment inaccuracies on file rather than taking punitive action against the provider, even though such action is available.
We encourage providers to:
- Immediately review enrollment data on file and make necessary corrections.
- Ensure that the compliance activities of the provider, regardless of provider size, are sufficient to better ensure compliance with existing, proposed, and future regulations. This may mean that outside services are secured to meet this end.
- Think broadly about compliance as compliance extends beyond Medicare and Medicaid to tax-related matters, personnel-related matters, etc.
Of potential interest to providers is the upcoming CMS National Provider Enrollment Conference, August 28-29, 2024, San Diego Convention Center. Details are available at https://med.noridianmedicare.com/web/medicare/national-provider-enrollment-conference. Ms. Christy Conaway and Ms. Amanda Makon of The Health Group, LLC will be attending.