The Centers for Medicare and Medicaid Services recently issued a final rule that updates requirements and strengthens program integrity efforts.
The Centers for Medicare and Medicaid Services (CMS) recently issued a final rule that updates requirements for providers wishing to enroll in the Medicare program. The updates, effective February 3, 2015, are the latest in a longstanding effort by CMS to strengthen Medicare program integrity efforts.
Enrollment is a critical gateway to billing the Medicare program and, as such, is carefully scrutinized by CMS to ensure only legitimate providers enroll. The final rule makes several key changes impacting enrollment:
These changes underscore the importance of creating and fostering a “culture of compliance” within healthcare, and encourage providers to conduct business with potential program integrity risks and consequences squarely in mind. Some key takeaways that payers, and providers in their networks, may find helpful include:
With whom are you doing business? As CMS reminds us, “[I]t is ultimately the hiring provider or supplier’s responsibility” to check backgrounds of any individuals or entities with which the organization is doing business.
Keep your eyes on the contractors. Pay close attention to this newly-strengthened billing revocation authority, because CMS and its contractors may use it with increased frequency as a tool in their program integrity arsenal. CMS’s ability to revoke a provider’s billing privileges is tantamount to payment exclusion and comes with administrative appeal rights that, for most providers, afford too few protections that are not available when needed most. Moreover, the combination of strong billing revocation authority and a potential 10-year look-back period for overpayments under the federal False Claims Act signals a critical need to take a cautious approach to assessing potential risks within organizations. In February 2012, CMS published a proposed rule regarding reporting and returning of overpayments; if it is ultimately finalized, it could create retroactive liabilities and is inconsistent with government and industry practice regarding document retention, Medicare’s longstanding “reopening” provisions for adjudicated claims, and even underpayment liability look-back provisions.
George B. Breen is a member ofand Amy Lerman is an associate at Epstein Becker Green’s Health Care and Life Sciences Practice.