CMS and HHS Tighten Enrollment Rules and Increase Penalties

This ruling impacts what providers and suppliers are required to disclose to be considered eligible to participate in Medicare, Medicaid, and Children's Health Insurance Program (CHIP). The original proposed rule came out in 2016 and this final rule will go into effect on November 4, 2019. 

There have been known problems of individuals getting around the previous enrollment and re-enrollment rules through name changes, identity changes, and what CMS describes as “elaborate, inter-provider relationships.” This ruling is aimed at catching these individuals and allowing the OIG to take action against them. 

Disclosure Requirements

In summary, the ruling requires any enrolled provider to disclose any affiliation (direct or indirect) with a provider or supplier that has any of the following (currently or within the last five (5) years):

• Uncollected debt: This includes overpayments, civil monetary penalties, and assessments. When CMS determines that a claim was improperly paid, the amount is considered an overpayment. Even if this amount is being disputed, appealed, or is in the process of being repaid (payments are being made, but there is still an outstanding balance) by the provider/supplier, it is still considered uncollected debt.
• Suspension: Provider/supplier is currently or has been the subject of a payment suspension “regardless of when the payment suspension occurred or was imposed.”
• Exclusion: Provider/supplier is currently or has been excluded by the Office of Inspector General (OIG), even if it is being appealed.
• Billing privileges denied/revoked/terminated: The reason, appeal status, or date does not matter. This includes voluntary termination by the provider/supplier.

It should be noted that the above items do not necessarily mean that the provider/supplier making the disclosure will be automatically excluded from participation in these federal programs. Rather, that the information is necessary for CMS to evaluate the potential risk on a case-by-case basis.

There is also a new “reapplication bar.” If an “enrollment application is denied because the provider or supplier submitted false or misleading information on or with (or omitted information from) its application in order to gain enrollment in Medicare”, they would be barred from re-applying for up to 3 years.

There have been concerns expressed about the enrolling provider not being able to know or obtain all this information about an affiliated provider/supplier. CMS will use what they call a “reasonableness” test “in determining whether the disclosing entity knew or should have known the information.” CMS will be issuing other guidance regarding what is required by the disclosing entity. 

Re-enrollment Bar Period

When a provider/supplier has had their billing privileges revoked, they are currently barred from re-enrollment for a period of 1-3 years, depending on the severity of the revocation. The final rule increases the maximum period from three to 10 years if this is the first time that they have been barred. If this is the second offense, the maximum increases to 20 years. 

If CMS determines that a provider/supplier “is attempting to circumvent its existing reenrollment bar by enrolling in Medicare under a different name, numerical identifier, or business identity,” they can add up to 3 more years to their re-enrollment bar.

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