Medicare Seeks to Toughen Provider Enrollment Process

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By James Swann

Feb. 25 — Medicare would have new ways of blocking potentially fraudulent providers from receiving money from the program under a CMS proposal released Feb. 25.

The proposed rule from the Centers for Medicare & Medicaid Services would fight Medicare fraud by requiring providers to disclose affiliations with individuals who owe money to Medicare, Medicaid or the Children's Health Insurance Program or have been suspended or revoked from participating in federal health-care programs. The disclosure would be required when providers are enrolling or re-enrolling to participate in the program.

Providers would have to disclose affiliations going back five years, because the CMS said relationships with troubled providers might be a warning sign of problems involving the enrolling provider.

The CMS defined affiliation as having a 5 percent or greater ownership interest in another individual's business, having a general or limited partnership interest or acting as an officer or director.

A key to curbing health-care fraud is to prevent it before it occurs, and the proposed rule appears to be on the right track, Louis Saccoccio, chief executive officer of the National Health Care Anti-Fraud Association, told Bloomberg BNA Feb. 25.

Saccoccio said one of the best ways to do this is implement a process that can effectively screen high-risk providers before they have a chance to start billing Medicare.

“This proposed rule is a commonsense step that further strengthens the screening process by keeping out providers that have had a problem in the past,” Saccoccio said.

Compliance Issues

While acknowledging that the proposed rule seeks to implement commonsense disclosures from the ACA, compliance may be an issue, Kirk Ogrosky, an attorney with Arnold & Porter in Washington, told Bloomberg BNA Feb. 25.

“The problem with these types of rules is that those intent on committing fraud don't comply and aren't interested in compliance,” Ogrosky said.

Ogrosky likened the proposed rule to setting up a roadblock for someone who refuses to drive on the road.

“It doesn't even slow them down,” Ogrosky said.

The proposed rule, which implements provisions of the Affordable Care Act, also would block providers from participating in the Medicare program if they had been kicked out of the program under a different name or had a history of abusive drug prescribing.

Providers also would be banned for 10 years from re-enrolling in the program if their billing privileges are revoked. Currently, the re-enrollment ban is just three years.

Comments on the proposed rule (CMS-6058-P, RIN 0938-AS84), which will be published in the March 1 Federal Register, are due April 25.

The proposal is the latest step from the CMS to tightening provider enrollment procedures, following a 2011 final rule that implemented automated risk-based screening.

Enrollment Provisions

In addition to the required affiliation disclosures, the proposed rule would:

  •  prevent a provider from enrolling in Medicare for up to three years if a previous enrollment application was denied due to the presence of false information; and
  •  deny a Medicare enrollment application if the provider was currently suspended from any other federal health-care program or had a revoked or suspended medical license.

    Compliance with the proposed rule is expected to cost providers an average of $290 million in each of the first three years of implementation. The CMS said the proposal would benefit federal health-care programs by keeping out troublesome providers, but it couldn't quantify how much would be saved.

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    To contact the editor responsible for this story: Kendra Casey Plank at

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