Health care facilities and physician groups need to closely monitor their members, entities, and disclosure activities. Often, problems with Medicare or Medicaid enrollment or revalidations are due to a surprise sanction report on a board member or physician member.
Starting November 4, 2019, a new rule called Program Integrity Enhancements to the Provider Enrollment Process (CMS-6058-FC) goes into effect. CMS will have new enforcement authority and a longer reach to prevent Medicare, Medicaid and CHIP related criminality. CMS hopes to stop fraud and abuse before it happens by preventing relationships that pose potential threats.
The final rule creates new revocation and denial authorities which strengthen federal enforcement efforts. The most impactful part of this rule is the new “affiliations” authority. The affiliations authority allows CMS to identify and prevent people and entities from participating in Medicare, Medicaid, and CHIP, who pose an undue risk of fraud, waste or abuse based on their affiliations with sanctioned entities.
While the concept of disclosing sanctions and other violations is not new, the enforcement process now has a proactive approach. Instead of focusing on recovery after the fact, CMS will now block those who have or had affiliations with violators, from achieving certification. Enrollees and members will have to report any current or previous affiliations with entities or individuals who (1) have uncollected debt; (2) have been or are subject to a payment suspension under a federal health care program; (3) have been or are excluded by the Office of Inspector General from Medicare, Medicaid, or CHIP; or (4) have had their Medicare, Medicaid, or CHIP billing privileges denied or revoked. CMS defines affiliation to include any of the following:
- Direct or indirect ownership of 5% or more in another organization;
- A general or limited partnership interest, regardless of the percentage;
- An interest in which an individual or entity “exercises operational or managerial control over, or directly conducts” the daily operations of another organization, “either under direct contract or through some other arrangement;”
- When an individual is acting as an officer or director of a corporation; and
- Any reassignment relationship.
If CMS determines that there is an undue risk of fraud, waste or abuse based on an affiliation with a previously sanctioned provider or supplier, CMS may deny or revoke enrollment to the entity. For example, CMS may deny or revoke the enrollment of a provider where one of the provider’s owners or managing employees had an ownership interest or other affiliation, as defined above, with a previously sanctioned entity, if such affiliation poses an undue risk.
In addition to allowing CMS to deny and revoke enrollments due to affiliations that pose an undue risk of fraud, waste or abuse, the new rule gives CMS more power to revoke and deny participation in Medicare/Medicaid programs for those guilty of the following:
- Trying to enroll into the Medicare program under a different name;
- Billing for services or items from noncompliant locations;
- Exhibiting “a pattern or practice of abusive ordering or certifying of Medicare Part A or Part B items, services or drugs;” and
- Owing CMS money from an overpayment referred to the US Treasury Department.
Under the new rule, CMS can also prevent applicants from enrolling in the program for up to 3 years if they are found to have submitted false or misleading information in their initial enrollment application. The new rule also allows CMS to block providers and suppliers who are revoked from re-entering the Medicare program for up to 10 years, a substantial increase over the previous 3-year bar. If revoked from Medicare for a second time, a provider or supplier can be blocked from re-entering the program for up to 20 years. However, an affiliation with a previously sanctioned provider or supplier does not automatically disqualify an entity from participating in Medicare, Medicaid or CHIP. This final rule comes with a comment period.
Talk to Advis. Advis encourages the submission of questions and comments and will assist providers upon request. Please contact us for further information.