CMS Final Rule (Fraud) [Healthcare Compliance Tips]

Evaluate CMS’s new enforcement authorities to reduce fraudulent behavior.

On Sept 5, 2019, CMS announced new enforcement authorities to reduce fraud within Medicare, Medicaid, and CHIP.

The new authorities and restrictions will be effective by November 4, 2019, in which CMS can revoke or deny the enrollment application due to the following:

• A provider or supplier circumvents program rules by coming back into the program, or attempting to come back in, under a different name (e.g., the provider attempts to “reinvent” itself);

• A provider or supplier bills for services/items from non-compliant locations;

• A provider or supplier exhibits a pattern or practice of abusive ordering or certifying of Medicare Part A or Part B items, services or drugs; or

• A provider or supplier has an outstanding debt to CMS from an overpayment that was referred to the Treasury Department.

CMS states:

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.   

 And by revoked that means the following can occur:

• A provider or supplier will be barred for up to 3 years for submission of false or misleading information.

• A previously revoked provider or supplier can be blocked from reentering the program for up to 10 years (or 20 years for a second time).

Remember, healthcare organizations that make a good faith effort to protect the system will not be affected by the changes.  But, we do suggest that you talk with your team about the new changes, which also includes revaluation of the exclusion process.

**The opinions and observations from the group/author are not a promise to exempt your practice from fines and penalties.  Research, modify, and tailor the advice to fit your specialty.