CMS Proposes Revisions to Provider Enrollment Requirements
June 6, 2013 10:49 AM
In an April 2013 notice of proposed rulemaking (NPR) the Centers for Medicare & Medicaid Services (CMS) made known its plans to add new requirements to provider enrollment and expansion of CMS authority to revoke Medicare billing privileges. This NPR also proposes revisions to the Incentive Reward Program by increasing the reward amounts to individuals who report information leading to identification of fraudulent activity.
Incentive Reward Program
As required by the Health Insurance Portability and Accountability Act (HIPAA), CMS established a program for encouraging the reporting of information about individuals or entities engaging in acts that serve as grounds for the imposition of sanctions or engage in Medicare or Medicaid fraud. In this notice, CMS proposes to increase the potential reward in order to motivate more individuals to review their Medicare Summary Notice and report suspicious activity. Criteria under which CMS will issue rewards, plans to limit rewards to the first individual who provides information, new attestation requirements, and notification of eligibility are addressed.
Expanded Provider Enrollment and Revocation
Further, changes to enrollment requirements and additional basis for revocation or billing privileges have been proposed. A minor informational change is proposed to the definition of Medicare enrollment to include enrollment via the 855-O of those individuals who wish solely to order and refer Medicare for services. However, several other changes to enrollment limitations and the deactivation of billing privileges have been proposed. These proposals must be carefully analyzed in order to determine their impact on new and existing home health and hospice providers.
Below is a brief summary of these proposed changes:
Expands denial of enrollment to any provider, supplier, or current owner that was the owner of a prior provider or supplier that had a Medicare debt (changed from overpayment) when that other provider’s enrollment was terminated – either voluntarily or involuntarily - if:
The owner left within one year of the termination
The debt has not been fully repaid or an extended repayment plan has not approved
CMS determines that the debt poses an undue risk of fraud, waste or abuse
Expands denial of enrollment or revocation of Medicare billing privileges to include managing employees if the provider, supplier, owner or managing employee was convicted of a felony within the past 10 years. Managing employees would be inclusive of corporate officers and directors and/or board of directors.
Expands revocation to include findings that a provider is no longer operational or otherwise fails to satisfy any Medicare enrollment requirements.
Expands prohibitions to include any felony conviction within the preceding 10 years rather than a defined list of felonies, including guilty pleas and adjudicated pretrial diversions that are determined to be detrimental to the best interests of the Medicare program.
Adds felony convictions of managing employees.
Expands revocation of Medicare billing privileges if the provider or supplier has a pattern or practice of billing for services that do not meet Medicare requirements, such as services that were not reasonable or necessary, a pattern of inaccurate or erroneous claim submissions, or where a beneficiary is deceased.
Requires all revoked providers and suppliers to submit remaining claims within 60 days after their revocation except home health agencies which must submit claims within 60 days of the date that the last home health agency episode ends or 60 days after revocation, whichever is later.
Specifies that all re-enrollment bars begin 30 days after CMS or its contractors mail notice of the revocation determination except for failure to revalidate, to which the enrollment bar does not apply.
Corrective Action Plan Limitations
CMS also plans to amend 405.809 to allow providers the ability to submit a corrective action plan (CAP) to violations of 424.535(a)(1) but to limit them to one opportunity to correct all of the deficiencies that served as the basis for a revocation.
CMS proposed this change to ensure that provider that only minimally failed o comply with enrollment requirements can quickly and easily be corrected. A CAP should not be available if a provider is revoked based on an OGI exclusion or felony conviction of false or misleading information, or failure to change practice locations. In these cases a formal appeal would be required.
Considerations for Comments
The proposed rule raises a number of concerns due to the unlimited and ill-defined authority it affords CMS. For example, the new requirement on prior debt, which will require reporting affiliation with previous providers, fails to address consideration of outstanding Medicare appeals of prior debts.
Further, although CMS identifies the amount of debt, length of timeframe an individual was an owner, and the percentage of ownership as considerations in its analysis for denying enrollment, it does not establish measurable targets for decision making. CMS has solicited comments on the considerations it has identified and seeking suggestions of others that should be included for enrollment of owners with prior debt to the Medicare program.
CMS is also soliciting comments on its proposal to expand the revocation of Medicare billing privileges if a provider or supplier has a pattern or practice of billing for services that do not meet Medicare requirements, and/or a pattern of inaccurate claims submission. CMS intends to “focus on submission of numerous or abnormally high volume of claims denied over time…” CMS is seeking comments on its plan to include such things factors as: the percentage of submitted claims denied, total number of claims denied, the reason for denial, history of final adverse actions, the length of time over which the pattern continued and how long the provider has been enrolled.
CMS is also looking for recommendations for additional factors to consider, what not to consider, whether greater or lesser weight should be applied to factors, a minimum or maximum threshold for percentage of claims denied, a total number denied, and knowledge standard (i.e. reckless disregard versus knew or should have known).
Serious consideration must be given to this proposal in light of problems providers have experienced with medical review decisions by the various contractors. Also, the proposal fails to address how denials that are overturned upon appeal will be factored.
CMS did not request comments on its proposals to expand felonies to “any that have been determined to be detrimental to the Medicare program.” However, providers should be prepared to weigh in on whether a bright line test should be in place for making this determination, rather than leaving this decision totally in the hands of CMS.
The public is invited to comment on the proposed rule. Comments must be submitted by 5:00pm EST on June 28, 2013.
Instructions for submission of comments can be found in the Federal Register notice here.