Major Changes to Provider Enrollment

Major Changes to Provider Enrollment
The Centers for Medicare and Medicaid Services (CMS) has announced major changes in provider enrollment effective on November 4, 2019. These changes will allow CMS to revoke healthcare providers or suppliers’ Medicare/Medicaid enrollment if they are affiliated with “bad actors” and pose an undue risk of fraud, waste or abuse based on their relationships with other sanctioned providers. The notice of the final rule implementing these changes appeared in the Federal Register on September 10, 2019.

As of the effective date, Medicare and Medicaid providers will be required to disclose current or previous affiliations with organizations that have:
• Uncollected debt;
• Had a payment suspension under a federal healthcare program;
• Been excluded from either the Medicare and/or Medicaid Programs; or
• Had billing privileges denied or rescinded.
In addition, CMS will be able to revoke or deny enrollment if providers and suppliers:
• Attempt to get back into the program under a different name;
• Bill for services from non-compliant locations;
• Exhibit a fraudulent or wasteful pattern of ordering services or drugs; or
• Have an outstanding debt to CMS from an overpayment that was referred to the Treasury Department.
Providers that falsify enrollment applications may be prohibited from enrolling in the Programs for up to three years.

CMS says that it expects these provisions will cause 2600 new withdrawals of providers per year from the Programs. Providers may face a number of difficulties related to these new rules.

Perhaps most importantly, it is unclear whether providers who are subject to these rules will receive a meaningful opportunity to appeal. Providers need an opportunity to be heard before disenrollment under these rules occurs. If providers are disenrolled from the Programs prior to their appeals, the consequences are likely to be the same, i.e., providers will go out of business because they cannot go without payments from the Medicare and Medicaid Programs for extended periods of time.

It is also important to note that the likely consequence of new disclosure requirements is that some managers, owners and directors will become unemployable in the healthcare industry because of their past affiliations. As a result of these rules, it now matters with whom providers have associated.

In short, the consequences of these rules for providers are potentially very severe. Historically, at least anecdotally, the completion of the enrollment process has not gotten the attention it deserves. Now is the time to tighten up the enrollment ship!

©2019 Elizabeth E. Hogue, Esq. All rights reserved.

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