UPDATE: New CMS Program Integrity Rule Now in Effect

The Centers for Medicare & Medicaid Services’ (CMS) final rule addressing program integrity and vulnerability issues, which was issued on September 5, 2019, went into effect on November 4, 2019. As AGG discussed in an earlier posting, the new rule is intended to prevent bad actors from circumventing Medicare requirements by using elaborate inter-provider relationships, or through name and identity changes—all fraudulent schemes identified by the Office of Inspector General (OIG) as problematic in testimony before Congress in 2011.

As a reminder, the major provisions of the rule include:

Affiliation disclosure: the new rule will require that Medicare, Medicaid, and CHIP providers and suppliers provide broader disclosures regarding negative histories (e.g., if such provider has had Medicare, Medicaid, or CHIP billing privileges denied or revoked).

Revocation authority: CMS will have the authority to deny or revoke a provider or supplier’s Medicare enrollment if it is determined that the provider or supplier’s enrollment is currently revoked under a different name, numerical identifier, or business identity, and the reenrollment bar period has not expired.

Increase in enrollment bar: Previously, the maximum enrollment bar was 3 years. The new rule increases that bar to 10 years, with some exceptions. Also, a provider or supplier may be prohibited from enrolling in the Medicare program for up to 3 years if its application is denied due to submission of false or misleading information, or omission of information from its application for enrollment.

These changes are but one of the many ways that CMS is making the application and enrollment process more transparent. Medicare, Medicaid, and CHIP providers and suppliers will recognize these changes as they report ownership or other disclosures in applications or renewals submitted to CMS. To the extent not already completed, such providers and suppliers should review the language of the new Rule and be prepared to provide additional information in these applications.

For more information, please contact Hedy Rubinger or Alexander Foster.