Written By Melony Anderson
On December 3, the Centers for Medicare & Medicaid
Services (“CMS”) issued a new rule that enhances CMS’s ability to exclude or
remove providers from participation in Medicare. According to a press release issued by CMS,
the new rule is designed to “prevent physicians and other providers with unpaid
debt from re-entering Medicare, remove providers with patterns or practices of
abusive billing, and implement other provisions to help save more than $327
million annually.”
The new rule has several provisions. The first, and most significant given CMS’s
stated purpose for the rule, is as follows:
CMS may now deny enrollment if
the provider, supplier or owner thereof was previously the owner of a provider
or supplier that had a Medicare debt that existed when the latter’s enrollment
was voluntarily terminated, involuntarily terminated or revoked AND
· The
owner left the provider or supplier that had the Medicare debt within 1 year of
that provider or supplier’s voluntary termination, involuntary termination, or
revocation;
· The
Medicare debt has not been fully repaid; AND
· CMS
determines that the uncollected debt poses an undue risk of fraud, waste or
abuse.
There are terms under which the provider, supplier or owner
thereof can avert the denial, including repaying the debt in full, or agreeing
to a repayment schedule for the entire debt if the provider meets the criteria
for an extended repayment schedule provided by 42 C.F.R. §401.607.
To illustrate how this rule may be applied, consider the
following example. Provider ABC is owned
by Owner X. ABC terminates its
enrollment in Medicare. At the time of
the termination, ABC had an outstanding Medicare debt. Owner X leaves ABC less than a year after the
termination. Thereafter, as long as
ABC’s debt remains unpaid, Owner X may be excluded from participating in
Medicare, either as a provider or supplier or as an owner thereof, if CMS
determines that the outstanding debt poses an “undue risk of fraud, waste or
abuse.” It is not clear from the rules
what CMS considers to constitute an “undue risk”, and whether that is based on
a dollar figure, or some other criteria.
Owner X may avoid denial if he/she agrees to a repayment schedule for
the debt, or pays the debt in full.
The new rule also expands the bases on which CMS can deny
enrollment or revoke billing privileges based on prior felony convictions. Under the prior rule, CMS could deny
enrollment to any provider, supplier or owner who was convicted of a state or
federal felony in the prior 10 years.
The new rule expands that to include “managing employees”.
CMS can now revoke Medicare billing privileges if the
provider or supplier has a “pattern or practice of submitting claims that fail
to meet Medicare requirements”, including the requirement that the service be
reasonable and necessary. Many
commenters to the proposed rule suggested that the provision was arbitrary and
subjective, granting too much discretion to CMS. CMS responded by stating that “sporadic
billing errors would not result in revocation”.
CMS does not define “pattern or practice”, but listed several factors
that would be considered, including: (1)
percentage of submitted claims that were denied; (2) total number of claims
denied; (3) the reason(s) for the claim denials; (4) whether there is a history
of final adverse actions; (5) the time period over which the pattern has continued;
and (6) how long the provider has been enrolled in Medicare. With respect to factors (1) and (2), CMS
declined to establish objective numerical thresholds.
The new rule also provides that revoked providers must
submit all remaining claims within 60 days after revocation. Revoked providers and suppliers may now only
submit a corrective action plan where the revocation was based on noncompliance
with the enrollment requirements, or the enrollment application. In other words, a revocation based on provider
or supplier conduct is no longer eligible for a corrective action plan.
The new rule goes into effect on February 3, 2015.
No comments:
Post a Comment