Find-A-Code Focus Newsletter

CMS - Final Rule to Deny or Revoke the Enrollment of Entities that Pose an Integrity Risk to Medicare

December 16, 2014


On December 3, 2014, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that will improve CMS’ ability to deny or revoke the enrollment of entities and individuals that pose a program integrity risk to Medicare.

This fact sheet summarizes CMS’ regulatory additions and changes.

SUMMARY OF THE PROVIDER ENROLLMENT PROVISIONS

Provider enrollment is the gateway that allows health care providers to bill for services provided to Medicare beneficiaries. CMS routinely evaluates its provider enrollment policies, and has implemented new safeguards as a result of provisions in the Affordable Care Act. In the February 2011 final screening rule (76 FR 5862), CMS revised its enrollment policy in order to increase the integrity of the Medicare program. CMS is now finalizing a number of additional provider enrollment provisions, including the following:

  • Adding the ability to deny the enrollment of providers, suppliers, and owners affiliated with an entity that has unpaid Medicare debt. This will help prevent individuals and entities from being able to incur substantial debt to Medicare, leave the Medicare program and then re-enroll as a new business to avoid repayment of the outstanding Medicare debt. CMS will only enroll otherwise eligible individuals or entities if they repay the debt or enter into a repayment plan.
  • Adding the ability to deny the enrollment or revoke the billing privileges of a provider or supplier if a managing employee has been convicted of certain felony offenses. This provision ensures that CMS can block or remove bad actors from the Medicare program to protect beneficiaries and safeguard the Medicare Trust Funds.
  • Permitting CMS to revoke billing privileges of providers and suppliers that have a pattern or practice of billing for services that do not meet Medicare requirements. This is intended to address providers and suppliers that regularly submit improper claims in such a way that it poses a risk to the Medicare program.
  • Making the effective date of billing privileges consistent across certain provider and supplier types. Most practitioners and practitioner groups may only submit bills as of the filing date of their enrollment application or the date of first furnishing services at a new practice location, whichever is later. CMS is now eliminating ambulance suppliers’ previous ability to bill for up to a year prior to enrollment in the Medicare program. Also, CMS now requires that ambulance providers and other provider and supplier types submit any claims within 60 days of the revocation of their billing privileges, consistent with the requirements for practitioners and practitioner groups. This provision is estimated to save $327 million annually.

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