New Rule Augments CMS’s Fraud-Fighting Powers

On September 5, the Centers for Medicare & Medicaid Services (CMS) announced the issuance of a final rule that will allow the agency to deny or revoke a healthcare provider’s or supplier’s federal program enrollment if it is “affiliated” with another previously revoked organization. The rule had originally been proposed more than three years ago.

The goal of the “Medicare, Medicaid, and Children’s Health Insurance Programs; Program Integrity Enhancements to the Provider Enrollment Process” rule (CMS-6058-FC) is to allow CMS to stop healthcare waste, fraud and abuse before the fraudsters get paid. The rule’s new “affiliations” authority gives CMS the ability to make enrollment decisions based on an entity’s (or its ownership’s or management’s) relationships with other previously sanctioned entities.

The new rule also allows CMS to bar a federal program applicant for up to three years if it is found to have submitted false or misleading information in its initial enrollment application, and expands CMS’s right to revoke or deny enrollment for improper billing and other types of rules violations. In addition, the reenrollment bar which allows CMS to block revoked providers from re-entering the Medicare program has been expanded from three years to 10 years (or up to 20 years for repeat offenders).

The final rule will be effective November 4, 2019.