Providers Beware: Medicare Proposes Harsh New Screening Requirements

The Centers for Medicare & Medicaid Services (CMS) has once again proposed new rules which would enhance the screening requirements for providers and suppliers. The rule proposals would ratchet up the scrutiny on provider enrollments and toughen suspension and revocation penalties.

The proposed new rule would require disclosure of affiliations with entities and individuals that: (1) have uncollected debt; (2) have been or are subject to a payment suspension under a federal health care program; (3) have been excluded from Medicare, Medicaid or CHIP; or (4) have had their Medicare, Medicaid or CHIP billing privileges denied or revoked. Denial of enrollment or revocation of existing provider billing privileges are proposed for those provider where it is determined that the affiliation would pose an undue risk of fraud, waste, or abuse.

Other proposed changes include denying or revoking 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, and the applicable reenrollment bar period has not expired.

CMS is also proposing to 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.

Other proposed requirements would 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.

In the proposed rules, CMS wants to increase the maximum reenrollment bar from 3 to 10 years (with some exceptions).

Other measures that CMS proposes would: (a) permit 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; (b) impose a maximum 20-year re-enrollment bar if the provider or supplier is being revoked from Medicare for the second time; (c) deny a provider’s or supplier’s Medicare enrollment application if (i) the provider or supplier is currently terminated or suspended (or otherwise barred) from participation in a particular state Medicaid program or any other federal health care program; or (ii) the provider’s or supplier’s license is currently revoked or suspended in a state other than that in which the provider or supplier is enrolling.

Finally, the rule proposes to expand the existing ordering/certifying requirements to mandate that physicians and eligible professionals who order, certify, refer, or prescribe any Part A or B service, item, or drug must be enrolled in or validly opted-out of Medicare.

Comments to the Rule can be submitted by April 25, 2016.

If you have questions regarding Medicare and Medicaid enrollment, revalidation, revocation, denial or rejection of enrollment, Medicare appeals, exclusions, debarrments or if you question concerning other health care law matters, you may contact our office