CMS Enacts Medicare, Medicaid and CHIP Fraud-Fighting Rules

A final rule that went into effect Nov. 4 strengthens the Centers for Medicare and Medicaid Services’ ability to stop fraud before it happens. Program Integrity Enhancements to the Provider Enrollment Process “creates several new revocation and denial authorities to bolster CMS’s efforts to stop waste, fraud and abuse. Importantly, a new “affiliations” authority in the rule allows CMS to identify individuals and organizations that pose an undue risk of fraud, waste or abuse based on their relationships with other previously sanctioned entities. For example, a currently enrolled or newly enrolling organization that has an owner/managing employee who is “affiliated” with another previously revoked organization can be denied enrollment in Medicare, Medicaid and CHIP [Children’s Health Insurance Program] or, if already enrolled, can have its enrollment revoked because of the problematic affiliation.

In addition to the affiliations component, CMS has enacted other measures to revoke or deny Medicare enrollment if:

• A provider or supplier circumvents program rules by coming back into the program, or attempting to come back in, under a different name (e.g., the provider attempts to “reinvent” itself);
• A provider or supplier bills for services/items from noncompliant locations;
• A provider or supplier exhibits a pattern or practice of abusive ordering or certifying of Medicare Part A or Part B items, services or drugs; or
• A provider or supplier has an outstanding debt to CMS from an overpayment that was referred to the Treasury Department.

In addition, the new rule gives CMS the ability to prevent applicants from enrolling in the program for up to three years if a provider or supplier is found to have submitted false or misleading information in its initial enrollment application. And, it expands the re-enrollment bar that prevents fraudulent or otherwise problematic providers from re-entering the Medicare program. CMS can now block providers and suppliers who are revoked from re-entering the Medicare program for up to 10 years, whereas they were previously prevented from re-enrolling for only up to three years. Lastly, if a provider or supplier is revoked from Medicare for a second time, CMS can block that provider or supplier from re-entering the program for up to 20 years.