Experience. Integrity. Advocacy.
Experience. Integrity. Advocacy.

New Provider Enrollment Provisions to Reduce Medicare Fraud


On December 3, 2014, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that will improve CMS’ ability to deny or revoke the enrollment of entities and individuals that pose a program integrity risk to Medicare.

Since provider enrollment is the gateway that allows healthcare providers to bill for services provided to Medicare beneficiaries, CMS routinely evaluates its provider enrollment policies and has implemented new safeguards as a result of provisions in the Affordable Care Act. In the February 2011 final screening rule, CMS revised its enrollment policy in order to increase the integrity of the Medicare program.

CMS is now finalizing a number of additional provider enrollment provisions, including the following:

  • Adding the ability to deny the enrollment of providers, suppliers, and owners affiliated with an entity that has unpaid Medicare debt. This will help prevent individuals and entities from being able to incur substantial debt to Medicare, leave the Medicare program, and then re-enroll as a new business to avoid repayment of the outstanding Medicare debt. CMS will only enroll otherwise eligible individuals or entities if they repay the debt or enter into a repayment plan.
  • Adding the ability to deny the enrollment or revoke the billing privileges of a provider or supplier if a managing employee has been convicted of certain felony offenses. This provision ensures that CMS can block or remove bad actors from the Medicare program to protect beneficiaries and safeguard the Medicare Trust Funds. Previously, this revocation of billing privileges applied only for owners or practitioners convicted of certain felony offenses. Now, however, it will apply to any provider, supplier, or any owner or managing employee of the provider or supplier. Additionally, Medicare now has discretion over what felony crimes are considered threatening to the Medicare program, including, but not limited to murder, rape, assault, and other similar crimes; financial crimes, such as extortion, embezzlement, income tax evasion, insurance fraud and other similar crimes; or any felony that placed the Medicare program or its beneficiaries at immediate risk, such as a malpractice suit that results in a conviction of criminal neglect or misconduct.
  • Permitting CMS to revoke billing privileges of providers and suppliers that have a pattern or practice of billing for services that do not meet Medicare requirements. This is intended to address providers and suppliers that regularly submit improper claims in such a way that it poses a risk to the Medicare program. In the final rule, the following factors were included for consideration of what constitutes a “pattern or practice”: the percentage of submitted claims that were denied, the reason(s) for the claim denials, whether the provider or supplier has any history of “final adverse actions,” the length of time over which the pattern has continued, and gow long the provider or supplier has been enrolled in Medicare.
  • Making the effective date of billing privileges consistent across certain provider and supplier types. Most practitioners and practitioner groups may only submit bills as of the filing date of their enrollment application or the date of first furnishing services at a new practice location, whichever is later. CMS is now eliminating ambulance suppliers’ previous ability to bill for up to a year prior to enrollment in the Medicare program. Also, CMS now requires that ambulance providers and other provider and supplier types submit any claims within 60 days of the revocation of their billing privileges, consistent with the requirements for practitioners and practitioner groups.

For more information about the new provider enrollment provisions, review the final rule of the Medicare Program; Requirements for the Medicare Incentive Reward Program and Provider Enrollment.

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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