Provider enrollment revalidation is just one part of the Centers for Medicare and Medicaid Services’ (CMS) ongoing and continuous effort to prevent questionable providers and suppliers from entering the Medicare program.
From 2011 through 2015, CMS implemented several processes to help shore up the integrity of the Medicare program. This infographic highlights some of the results of those actions:
In late February, CMS proposed several new regulations to further screen entities and individuals who pose a risk to the Medicare program. If finalized, the program enhancements would allow CMS to take action to remove or prevent the enrollment of health care providers and suppliers that attempt to circumvent Medicare’s enrollment requirements through name and identity changes as well as through elaborate, inter-provider relationships. The proposed provisions also address the problem of providers and suppliers avoiding payment of Medicare debts by re-enrolling as a different entity.
Major provisions of the proposed rule include:
- Required disclosure of affiliations that 1.) have uncollected debt owed to Medicare, Medicaid, or CHIP; 2.) have been or are subject to a payment suspension under a federal health care program or subject to an Office of Inspector General (OIG) exclusion; or 3.) have had their Medicare, Medicaid, or CHIP enrollment denied or revoked.
- Denial or revocation of Medicare enrollment if a provider or supplier has been previously revoked under a different name, numerical identifier, or business identity.
- Revocation of Medicare enrollment if a provider’s pattern or practice of ordering, certifying, referring, or prescribing Medicare Part A or B services, items, or drugs has been abusive, represents a threat to the health and safety of Medicare beneficiaries, or otherwise fails to meet Medicare requirements.
- Expansion of enrollment requirements (or valid opt-out) for providers who order, certify, refer, or prescribe any Part A or B service, item, or drug.
For more information, review the CMS Fact Sheet “Program Integrity Enhancements to the Provider Enrollment Process.”
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