CMS beefing up screening of Medicare-enrolled providers

To help combat Medicare fraud – and weed out those most responsible for it – the Centers for Medicare & Medicaid Services (CMS) is making changes in how providers enroll and remain in the Medicare system.

CMS plans to publish a new rule in the Federal Register tomorrow that creates added requirements for those enrolling to become Medicare providers and gives the agency tools to find and terminate enrolled providers who have shown a history of fraud. This has added significance as many physicians are coming up on the end of their five-year Medicare revalidation cycle and will be submitting information to maintain their billing privileges.

Among the changes:
• Providers would have to disclose connections to other providers or suppliers who have had their Medicare, Medicaid, or CHIP enrollment denied or revoked; have uncollected debt to those programs; or have had their payment suspended under a federal health care program or because of an Office of Inspector General exclusion.
• CMS could deny or revoke Medicare enrollment if it discovered a provider's Medicare enrollment has been revoked under a different name or identity. Also, it could deny or revoke Medicare enrollment if a provider’s license has been revoked in one state and he or she is applying or enrolled in a different state or if the provider has been terminated from a state Medicaid or other federal health care program under a current or different name or identity.
• The agency could revoke the physician's enrollment for what CMS considers an "abusive" or dangerous pattern or practice of ordering, referring, certifying, or prescribing Medicare Part A or B services, items, or medications.
• The length of time someone can be barred from re-enrolling in Medicare would increase, including a maximum 20-year ban for a second revocation.
• CMS would require that physicians and others who order, certify, refer, or prescribe any Part A or B service, item, or medication must be either enrolled in Medicare or have a valid opt-out.

Meanwhile, CMS is boosting its existing methods for screening Medicare providers by increasing site visits to Medicare-enrolled providers, replacing the current Provider Enrollment Chain and Ownership System (PECOS) with software that can also look for invalid addresses, and deactivating on a monthly basis enrolled providers who have not billed Medicare in the last 13 months.

The upshot is that while physicians have always needed to be careful when submitting documentation to accept Medicare patients, you may now need to increase those efforts, even if you don't have any Medicare skeletons lurking in your past.