On December 5, 2014, CMS published a final rule to strengthen its oversight of Medicare providers. The rule includes safeguards designed to prevent providers with unpaid debt from re-entering Medicare and to remove providers with a history of abusive billing. CMS estimates that these new safeguards, which become effective February 3, 2015, may save more than $327 million annually.

The changes, made to the provider enrollment provisions in 42 C.F.R. Part 424, Subpart P, make it much more difficult for the nearly 25,000 providers who have been removed from the Medicare program to re-enroll. “The changes announced today are common-sense safeguards to preserve Medicare for generations to come, while making the rules more consistent for all providers that work with us,” CMS Administrator Marilyn Tavenner said in the CMS press release. “The Administration is committed to using all appropriate tools as part of its comprehensive program integrity strategy shaped by the Affordable Care Act.”

The final rule includes provisions that:

  • Deny enrollment to providers, suppliers, and owners associated with an entity with unpaid Medicare debt, only allowing enrollment of otherwise eligible individuals or entities if they repay said debt or enter into a repayment plan. Individuals or entities that, within one year before or after the provider or supplier’s voluntary termination, involuntary termination, or revocation, had a partnership interest or a direct or indirect ownership interest of at least 5 percent in the provider or supplier whose Medicare debt has not been fully repaid will be subject to the new rule;
  • Deny enrollment or revoke the billing privileges of a provider or supplier if a managing employee has been convicted of felony offenses determined to be detrimental to Medicare beneficiaries;
  • Revoke billing privileges of providers and suppliers with a pattern or practice of billing for services not meeting Medicare requirements;
  • Streamline the effective date of billing privileges across certain provider and supplier types; for example, eliminating ambulance suppliers’ previous ability to bill for up to a year prior to enrollment in the Medicare program by requiring them to submit any claims within 60 days of the revocation of their billing privileges; and
  • Limit revoked providers and suppliers’ ability to submit corrective action plans.

To see the final rule click here. To read the full fact sheet click here. To read CMS’s press release click here.