On March 1, 2016, the Centers for Medicare and Medicaid Services (CMS) published a proposed rule entitled “Program Enhancements to the Provider Enrollment Process”. According to CMS, it is engaging in this new rule making in order to implement several program integrity provisions that were part of the Affordable Care Act.

The major provisions of the proposed rule address a number of program integrity measures that include –

Disclosure of Affiliations:

Health care providers and suppliers must 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.

Revocation of Enrollment:

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.

CMS can revoke a provider’s or supplier’s Medicare enrollment—including all of the provider’s or supplier’s practice locations, regardless of whether they are part of the same enrollment—if the provider or supplier billed for services performed at or items furnished from a location that it knew or should have known did not comply with Medicare enrollment requirements.

Abusive Ordering/Certifying:

CMS can 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.

Tightening Medicare Re-enrollment Bars:

The proposed rule raises the existing maximum re-enrollment bar from three years to 10 years and allows CMS to add 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. Additionally, the proposed rule would impose a maximum 20-year reenrollment bar if the provider or supplier is being revoked from Medicare for a second time

Cross – Terminations:

CMS can 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.

Overall each of these major provisions are part of a significant ongoing effort by CMS to exclude questionable providers and suppliers from Medicare enrollment as well as revoke or otherwise take action against bad actors. Providers and suppliers are likely to see even more CMS rulemaking related to program integrity and the enrollment, re-enrollment and revocation processes.

You can find a copy of the proposed rule here – https://www.gpo.gov/fdsys/pkg/FR-2016-03-01/pdf/2016-04312.pdf