Medicare Extends Ban on Provider Enrollment in Six States

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By Mike Stankiewicz

Current bans on ambulance and home health care providers in six states were extended another six months due to concerns about Medicare fraud.

In a notice (CMS-6059-N7) released July 27, the Centers for Medicare & Medicaid Services said the extensions were necessary due to a high risk of fraud and abuse associated with ambulance providers and home health agencies. The extension affects all new nonemergency ambulance providers in New Jersey, Pennsylvania, and Texas, and new home health agencies in Florida, Illinois, Michigan, and Texas. The CMS previously extended the bans in January.

Home-health and ambulatory service groups said the extension was not surprising. “We were expecting it by the end of the month, because that’s when the previous extension ran out,” William Dombi, vice president for law at the National Association for Home Care and Hospice in Washington, told Bloomberg BNA July 27. “They’ve been extending it for years.” Dombi is a member of Bloomberg BNA’s advisory board.

“There’s no surprise here,” Tristan North, senior vice president of government affairs at the American Ambulance Association in McLean, Va., told Bloomberg BNA July 27.

The Affordable Care Act gave the CMS authority to implement temporary enrollment bans on Medicare, Medicaid, or Children’s Health Insurance Program providers and suppliers to combat fraud and abuse. The temporary bans were originally imposed in July 2013 and covered enrollment in several counties in Florida, Illinois, and Texas, and were expanded to counties in Michigan, Pennsylvania, and New Jersey the following year. The CMS made the enrollment bans statewide in all six states in July 2016.

The extensions are effective July 29. The agency notice will be published in the Federal Register on July 28.

Home Health, Ambulatory Services React

The CMS concluded after examining Medicare data and consulting with state Medicaid agencies and state departments of emergency medical services that the extension would not create access to care issues. Dombi disagreed.

“At first the ban only applied to a few counties,” he said. “Then new, fraudulent home health agencies would open up just outside of those counties but still serviced the banned counties, so the CMS made the ban statewide. We thought that was overkill. There is a need for new home health agencies in certain states like Florida, but many of those are being blocked.”

Dombi said more specific remedies to combat fraud, including a service area ban, would be more appropriate.

“They didn’t implement [a service area ban] because they didn’t think they had the authority to make one,” he said. “The 21st Century Cures Act gave them that authority but they still haven’t done anything with it yet.”

North said he supports the statewide ban, but it’s not without its faults.

“We would like to see a more targeted approach, North said. “There are issues with the statewide ban as there are areas where additional ambulances are needed. There are some ambulance service providers who are having trouble getting certified, and as a result, aren’t getting reimbursed through Medicare. Some get about 50 percent of their transport volume from Medicare patients, so that reimbursement is critical for them.”

To contact the reporter on this story: Mike Stankiewicz in Washington at mstankiewicz@bna.com

To contact the editor responsible for this story: Brian Broderick at bbroderick@bna.com

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