Proposed Home Health Provider Enrollment Provisions Designed to Deter Fraud

On July 1, 2026, the Centers for Medicare & Medicaid Services (CMS) proposed a new rule that included certain enrollment-related policy changes under the Home Health Prospective Payment System (HHPPS) designed to “reduce improper Medicare payments and protect beneficiaries.”^[1]

As explained by CMS, “[t]he overarching purpose of the enrollment process is to help confirm that providers and suppliers . . . seeking to bill Medicare for services and items furnished to Medicare beneficiaries meet all applicable Federal and State requirements to do so.”^[2] Enrollment thus acts as “a ‘gatekeeper’ that prevents unqualified and potentially fraudulent individuals and entities from entering and inappropriately billing Medicare.”^[3] CMS is authorized to revoke enrollment for a variety of reasons spelled out in 42 CFR § 424.535(a).

Among other things, CMS has proposed the following:

• Removing the factors listed for consideration in revoking enrollment as set forth in the regulation because, according to CMS, “we must have the maximum flexibility to address all possible . . . scenarios without the rigid constrains of our existing factors.”
• “Expanding the basis for revocation based on false or misleading information on the enrollment application to false or misleading information on or associated with any CMS or Medicare enrollment-related form (including enrollment-related forms created by and/or submitted to CMS contractors).”^[4]
• Expanding CMS’s authority to revoke all provider enrollments by allowing such revocations to be based not just on a decision by CMS to revoke one of a provider’s enrollments but also on a decision by CMS to deny a provider’s enrollment since, according to CMS, “[s]ome enrollment denials . . . have been based on conduct as concerning to us as that leading to a revocation.”^[5]

Additional grounds for revoking or denying enrollment are being proposed including, among others:

• Requiring that hospices, home health agencies and suppliers of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) reenroll in Medicare if they experience certain changes in majority ownership, and denying or revoking enrollment if this requirement is violated.^[6]
• Authorizing denial or revocation of Medicare enrollment, not only if a provider has a suspended/revoked license in another state or has been suspended/revoked from Medicaid or another Federal Healthcare Program, but also if that provider’s owners or managing employees/organizations have suffered similar suspensions/revocations.^[7]
• Authorizing denial or revocation of Medicare enrollment if a provider or supplier has been convicted of a Federal or State misdemeanor related to sexual assault or financial misconduct within the past 10 years that CMS “deems detrimental to the best interests of the Medicare program and its beneficiaries.”^[8]

All grounds for Medicare enrollment revocations, some of which currently only become effective prospectively, would become retroactive. According to CMS, this will “help CMS recover monies paid to non-compliant providers and help ensure taxpayer money is paid only to legitimate, compliant providers.” ^[9] Some examples include the following:

• Revocation based on non-compliance with or failure to satisfy enrollment provisions effective “on the date the non-compliance began” or “the date the Medicare enrollment requirement was not satisfied.”^[10]
• Revocation based on a provider improperly selling or allowing another individual or entity to use its billing number to be effective on the date which the misconduct resulting in the revocation occurred, “given the seriousness of this conduct – with its significant potential for fraud.”^[11]
• Revocation based on a failure to comply with change of enrollment information reporting requirements will be retroactive to the day following the due date for reporting the change.^[12]
• Revocation based on DEA or state administrative revocation or suspension of drug prescribing authority will be effective as of the date of revocation or suspension.^[13]
• Revocation based on improper prescribing practices will be effective as of the last date of the prescriptions in question.^[14]
• Revocation based on a False Claims Act civil judgment within the prior 10 years would become effective on the date of the original judgment rather than prospectively, “[c]onsidering the seriousness of false claims and the threat this poses to the Medicare program.”^[15]
• Revocation based on failure to repay a debt that CMS properly referred to the Treasury would become effective as of the date CMS made the referral, given “the need to protect the Medicare program’s financial integrity.”^[16]
• Revocation based on a prior revocation under a different name would be effective as of the date of the provider’s original enrollment.^[17]
• Revocation based on abusive ordering, certifying, referring or prescribing would be effective as of “the last order, certification, referral, or prescription in the applicable pattern or practice.”^[18]
• Revocation based on prior action of a regulatory body that involved facts indicating physician or other eligible professional conduct leading to patient harm would be effective as of the date of that prior action.^[19]

Revised and new reasons for denial of enrollment were also proposed. CMS stated that these new authorities “would address situations noted by CMS as involving provider noncompliance and fraud, waste, and abuse” and “also would allow the agency to target improper activity by those who own or operate providers.”^[20]

If you have any questions about this article or the meaning of the proposed rule, you may contact the author at Geoffrey.Kaiser@rivkin.com or 516-357-3161.

^[1] 91 FR 41216, https://www.govinfo.gov/content/pkg/FR-2026-07-06/pdf/2026-13602.pdf

^[2] Proposed Rule, at p. 41283.

^[3] Id.

^[4] Id. at 41284.

^[5] Id. At 41285.

^[6] CMS Fact Sheet.

^[7] Id.

^[8] Proposed Rule at 41292.

^[9] CMS Fact Sheet, “Calendar Year (CY) 2027 Home Health Prospective Payment System Proposed Rule Fact Sheet,” accessible at https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2027-home-health-prospective-payment-system-proposed-rule-fact-sheet-cms-1844-p

^[10] Id. at 41286.

^[11] Id.

^[12] Proposed Rule, at 41287

^[13] Id.

^[14] Id. at 41288.

^[15] Id.

^[16] Id.

^[17] Id.

^[18] Id. at 41289.

^[19] Id.

^[20] CMS Fact sheet.