The Centers for Medicare and Medicaid Services (CMS) recently issued a final rule that includes several anti-fraud measures and significantly enhances the agency’s authority to exclude new and current providers and suppliers that are identified as posing an undue risk of fraud, waste, or abuse.
The new measures require providers and suppliers to disclose to CMS upon its request for initial enrollment, revalidation of any “affiliations” or parties who have one or more defined “disclosable events.”
The rule went into effect November 4, 2019.
The new rule requires all providers to disclose any current or prior affiliations within the past five years the provider—or any of its owning or managing employees or organizations—has had with a current or former Medicare provider with a “disclosable event.”
This can be triggered by any of the following:
- An uncollected debt to CMS.
- Current or previous payment suspension from a federal healthcare program.
- Current or previous exclusion from healthcare programs.
- Previous denial, revocation or termination of Medicare, Medicaid or Children's Health Insurance Program (CHIP) billing privileges.
The term “affiliation” is broadly defined to include any of the following conditions:
- A five percent or greater direct or indirect ownership in another organization.
- A general partnership interest in another organization.
- An interest in which the entity or individual exercises operational or managerial control over direct or indirect conducts.
- An interest in which the individual acts as an officer or director of a corporation.
- Any reassignment relationship under Title 42, Section 424.80 in the Federal Register, which prohibits reassignment of claims by suppliers under the Medicare program.