CMS Proposes Changes to Provider and Supplier Enrollment Rules
March 7, 2016 09:00 AM
The Centers for Medicare & Medicaid Services (CMS) has issued a proposed rule that would implement additional provider enrollment regulations aimed at providers and suppliers that attempt to circumvent Medicare’s enrollment requirements through name and identity changes as well as through elaborate, inter-provider relationships.
Disclosure of Affiliations: CMS would require health care providers and suppliers to report affiliations with entities and individuals that: (1) currently have uncollected debt to Medicare, Medicaid, or CHIP; (2) have been or are subject to a payment suspension under a federal health care program or subject to an Office of Inspector General (OIG) exclusion; or (3) have had their Medicare, Medicaid, or CHIP enrollment denied or revoked. CMS could deny or revoke the provider’s or supplier’s Medicare, Medicaid, or CHIP enrollment if CMS determines that the affiliation poses an undue risk of fraud, waste, or abuse.
The proposed rule defines ‘‘affiliation’’ as meaning, any of the following:
A 5 percent or greater direct or indirect ownership interest that an individual or entity has in another organization.
A general or limited partnership interest (regardless of the percentage) that an individual or entity has in another organization.
An interest in which an individual or entity exercises operational or managerial control over or directly or indirectly conducts the day-to-day operations of another organization (including, for purposes of § 424.519 only, sole proprietorships), either under contract or through some other arrangement, regardless of whether or not the managing individual or entity is a W–2 employee of the organization.
An interest in which an individual is acting as an officer or director of a corporation.
Any reassignment relationship under § 424.80.
Different Name, Numerical Identifier, or Business Identity: CMS could deny or revoke a provider’s or supplier’s Medicare enrollment if CMS determines that the provider or supplier is currently revoked under a different name, numerical identifier, or business identity.
Abusive Ordering/Certifying: CMS would revoke a physician’s or eligible professional’s Medicare enrollment if he or she has a pattern or practice of ordering, certifying, referring, or prescribing Medicare Part A or B services, items, or drugs that is abusive, represents a threat to the health and safety of Medicare beneficiaries, or otherwise fails to meet Medicare requirements.
Increasing Medicare Program Re-enrollment Bars: CMS proposes to:
Raise the existing maximum re-enrollment bar from three years to 10 years
Allow three more years to the provider’s or supplier’s re-enrollment bar if the provider attempts to re-enroll in Medicare under a different name, numerical identifier, or business identity
Impose a maximum 20-year reenrollment bar if the provider or supplier is being revoked from Medicare for the second time
Other Public Program Termination: CMS would deny or revoke a provider’s or supplier’s Medicare enrollment if: (1) the provider or supplier is currently terminated from participation in a particular Medicaid program or any other federal health care program under any of its current or former names, numerical identifiers, or business identities; or (2) the provider’s or supplier’s license is revoked in a state other than that in which the provider or supplier is enrolled or enrolling.
Expansion of Ordering/Certifying Requirements: CMS would require that physicians and eligible professionals who order, certify, refer, or prescribe any Part A or B service, item, or drug be enrolled in or validly opted-out of Medicare.
Application of Moratorium CMS proposes to relax restrictions for providers who are in the process of enrolling when a temporary moratorium is applied. A temporary moratorium would not apply to any enrollment application that has been received by the Medicare contractor prior to the date the moratorium is imposed. Currently, a temporary moratorium does not apply if the enrollment application has been approved but not yet entered into PECOS at the time the moratorium is imposed.
The proposed rule would expand the requirement that all Medicare providers and suppliers accept referrals, certifications or orders only from a Medicare-enrolled practitioner. This will require that hospice providers ensure that any hospice physician or attending physician chosen by the hospice beneficiary is either enrolled in or in active opt-out status in Medicare prior to submission of notices or claims to the Medicare Administrative Contractor (MAC) as inclusion of the NPI of a non-enrolled physician would result in rejection of the notice or claim.
The proposed rule raises serious concerns, particularly with regard to the complexity of the expanded reporting requirements on affiliations and the lack of specificity as to the standards that will be applied in determining whether a provider’s declared affiliations will result in revocation or denial of an enrollment agreement. In addition, the amount of information that would need to be disclosed, and whether a provider would even know if they have or have had an affiliation that requires them to disclose could place providers at undue risk for enrollment denials and revocations. Further, CMS proposes that the disclosure requirements be applicable to any affiliation if it was in place at any time during the previous 5 years.
To view the proposed rule click here. Comments are due April 25, 2016.