CMS Updates Program Integrity Manual
March 12, 2015 12:07 PM
The Centers for Medicare & Medicaid Services (CMS) has issued change request (CR) 9065 that incorporates provisions in the final rule (CMS-6045-F) entitled “Medicare Program; Requirements for the Medicare Incentive Reward Program and Provider Enrollment” into chapter 15 of the Medicare Program Integrity Manual. The CR also addresses several minor provider enrollment policy issues that have arisen recently.
The CR incorporates several provisions that strengthen enrollment policies related to denials and revocations. For example, reasons for denials related to existing overpayments now include providers and suppliers or owners that were previously the owner of a provider or supplier that had a Medicare debt. In addition, CMS includes several factors to be considered in determining if uncollected debt poses an undue risk of fraud, waste, or abuse.
Another key provision of the rule that is incorporated into the manual expands the reason for revocations related to abuse of billing privileges. A provider or supplier could have their billing privileges revoked if they show a pattern or practice of submitting claims that fail to meet Medicare requirements. In making this determination, the following factors are to be considered by CMS:
The percentage of submitted claims that were denied.
The reason(s) for the claim denials.
Whether the provider or supplier has any history of final adverse actions (as that term is defined in § 424.502) and the nature of any such actions.
The length of time over which the pattern has continued.
How long the provider or supplier has been enrolled in Medicare.
Any other information regarding the provider or supplier's specific circumstances that CMS deems relevant to its determination as to whether the provider or supplier has or has not engaged in the pattern or practice described in this paragraph.
The National Association for Home Care & Hospice (NAHC) raised concerns and submitted comments specifically regarding this provision when it was originally proposed by CMS.
In addition to incorporating provisions of the final rule, the CR updates and clarifies several other sections of chapter 15 of the PIM manual.
To view the full CR, please click here.