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Proposed enrollment rule will have practices rethinking relationships

What’s the worst thing that could happen to a practice if one of its partners hasn’t refunded and overpayment to the state’s Medicaid program? Under the proposed enrollment rule released on Feb. 25, the practice could have its application denied or revoked if it doesn’t report the debt during the enrollment or revalidation process.
It shouldn’t come as a surprise that CMS continues to close off routes to enrollment. It’s much easier – and cheaper – to keep crooks out of the program than to chase them down after the fact. The proposed rule, mandated by the ACA, would require providers to tell the agency every little thing about anyone who receives public health care dollars, including managers and providers who reassign their benefits to a practice.
Other people and entities that would be up for scrutiny include anyone who has a 5% or greater direct or indirect ownership interest in an organization, directors or officers and any person or entity that has a general or limited partnership interest.
Under the proposed rule there are three main types of “reportable events.” Providers would have to note a relationship with an individual or entity that has:
  1. An uncollected debt to Medicare, Medicaid, or CHIP.
  2. Been or is subject to a payment suspension under a federal health care program or subject to an HHS Office of Inspector General (OIG) exclusion.
  3. Had their Medicare, Medicaid, or CHIP enrollment denied or revoked.
CMS could deny or revoke the provider’s or supplier’s Medicare, Medicaid, or CHIP enrollment if CMS determines that the affiliation poses an undue risk of fraud, waste, or abuse.
The enrollment “time out” for providers would increase from three years to 10 with a maximum 20 year re-enrollment bar for providers that lose their enrollment for the second time.
But the proposed rule doesn’t stop there. CMS would be able to dump providers who might not break the law, but have a pattern of “ordering, certifying, referring or prescribing Medicare Part A or B services, items or drugs that is abusive, represents a threat to the health and safety of Medicare beneficiaries or otherwise fails to meet Medicare requirements.”
In addition, it would require any that provider who orders, certifies or prescribes any Part A or B service, item, or drug to enroll in Medicare or validly opt-out of the program.
The rule would go into effect Jan. 1, 2018, although CMS notes that it did consider a 2017 effective date. The 60-day comment period is scheduled to begin on March 1. As always, the easiest way to submit comments is through, and be sure to reference CMS-6058-P.
Watch PBN for more information on this rule.
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