It’s fall — and that usually means CMS will soon drop its final rule on the Medicare Physician Fee Schedule. But this September, a brand new final rule just fell into your lap: the “Program Integrity Enhancements to the Provider Enrollment Process” Final Rule.
This rule extends CMS’s authority to take action against “unqualified and potentially fraudulent entities and individuals.” More specifically, the rule broadens CMS’s power to deny or revoke a provider’s Medicare enrollment.
New Items You Must Disclose under the Medicare Enrollment Final Rule
You’re probably thinking, “I’m plenty qualified, and certainly not committing any type of fraud, so what’s this got to do with me?” Unfortunately, the final rule has implications even for providers who are completely on the up and up. How? Under this new Medicare enrollment rule you must disclose any current or previous, direct or indirect “affiliation” with other Medicare providers or suppliers who have:
- uncollected debt
- had payments suspended by federal healthcare programs
- been excluded from or denied enrollment in Medicare, Medicaid, and/or CHIP (the Children’s Health Insurance Program)
The Medicare enrollment final rule describes “affiliation” as:
- ownership interest of five percent or greater
- any general or limited partnership interest
- managerial or conduct of everyday operations
- acting as an officer or director
Example: A provider has ownership interest in several surgery centers, one of which was excluded from Medicare a few years ago due to a condition-level deficiency. In this case, the provider’s relationship with the surgery center qualifies as an “affiliate” and he or she must disclose it to CMS.
Under the new Medicare enrollment final rule, CMS has authority to revoke the provider’s Medicare billing privileges if CMS determines that due to the disclosure, the provider presents “an undue risk of fraud, waste, or abuse.”
The provider enrollment final rule also expands the circumstances under which CMS can revoke or deny Medicare enrollment, including if the provider/supplier:
- has had enrollment previously revoked under another name, numeric identifier, or business entity
- bills for services at a location that doesn’t comply with Medicare enrollment requirements (the provider must have known or should reasonably have known)
- “has a pattern or practice of ordering, certifying, referring, or prescribing” items or services payable under the Medicare program that CMS deems as “abusive” or “represents a threat to the health and safety of Medicare beneficiaries,” or “otherwise fails to meet Medicare requirements”
- has existing debt that CMS referred to the Department of Treasury
- is otherwise barred from another federal health care program
- currently has his or her license revoked or suspended in a state other than the state of enrollment.
Watch out: When you add providers to your practice, be extra careful when handling their Medicare enrollment. If a provider’s enrollment application is denied due to false, misleading, or missing information, that provider could be prohibited from enrolling in Medicare for up to three years.
Side Effects: What the Medicare Enrollment Final Rule Means for You
Are you 100 percent sure you’ve never associated — even unknowingly — with a provider or supplier who has debt or has committed fraud?
According to CMS, the final rule is aimed at career criminals who regularly conduct fraudulent activity while hiding within “complex, hard-to-track webs of criminal entities,” and is estimated to affect only 2,500-4,000 Medicare providers/suppliers.
However, it’s not difficult to see how law-abiding providers could get caught up in the final rule’s reach and become guilty — and subject to disenrollment — by association.
Not only that, but the final rule increases the penalties for regular non-compliance (you know, the kind your already worried about). Up until now, instances of non-compliance may have resulted in financial penalties or other corrective action by CMS.
But starting Nov. 4, 2019, CMS could revoke your Medicare enrollment for those same instances — basically, the penalty for non-compliance has gotten much stiffer.
Full Disclosure: 3 Steps to Comply with the Program Integrity Provider Enrollment Final Rule
While CMS will not require any disclosures until they have updated PECOS and the CMS 855 enrollment form, it’s wise to start preparing now. Here are a few things you can do to safeguard your Medicare enrollment under the new final rule:
- Make a list of potential “affiliations” with other Medicare providers and suppliers over the past five years, based on CMS’s criteria. This includes affiliations of your practice’s individual/organizational owners and managing employees (i.e. your practice administrator).
- Examine each affiliation for disclosable events, if any. Note that you must report any disclosable events, even those occurring outside of your period of affiliation.
- Stay tuned: CMS plans to publish more information on the affiliation reporting process.
Phased-In Approach Gives You Time to Prepare
CMS has given you some additional time to get your ducks in a row by adopting a “phased-in” targeted approach. You must take advantage of this transition to thoroughly understand how you can avoid getting blindsided because of an affiliate’s wrongdoing. You must know how to protect your practice from losing its ability to bill Medicare and Medicaid.
This is where Medicare expert, Gretchin Heckenlively, CPA, FHFMA, can help. During her online training session on, Gretchin walks you through the provider enrollment final rule, and tells you more steps you can take to protect your practice from harm.
This training gives you the practical actions you must take to prepare yourself for the full implementation of the Medicare enrollment rule, and how you can prevent losing Medicare and Medicaid billing privileges.
Training: Register for the training at CMS Final Rule: Prevent Revocation of Your Medicare Billing Privileges
Document: Read the Medicare Enrollment Final Rule (84 Fed. Reg. 47794) at https://www.federalregister.gov/documents/2019/09/10/2019-19208/medicare-medicaid-and-childrens-health-insurance-programs-program-integrity-enhancements-to-the