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ENROLLMENT: A NEW ENFORCEMENT TOOL?

On December 3, 2014, CMS issued its Final Rule that addresses provider enrollment. These new rules create new tools to police provider enrollment. CMS now has the ability to deny enrollment of providers, suppliers and owners who have been affiliated with an entity that has unpaid Medicare debt. CMS has announced that this provision will help prevent individuals and entities from incurring substantial Medicare debt, leaving the Medicare program, and then re-enrolling as a new business to avoid repayment of the outstanding Medicare debt. CMS has announced that it will only enroll eligible individuals or entities if they repay the debt or enter into a repayment plan.

  • CMS now has the ability to deny enrollment or revoke the billing privileges of a provider or supplier when a managing employee has been convicted of certain felony offenses.
  • CMS may now revoke billing privileges of providers and suppliers that have a pattern and/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.
  • CMS also established a rule concerning when certain provider and supplier types, including ambulances, may bill for services prior to the date of their enrollment. Essentially, CMS has eliminated the ability to ambulance suppliers to bill for up to a year prior to enrollment in the Medicare program.

While the specifics of the new regulations are not yet available, it is significant now that CMS has created the power to deny enrollment to a provider with unpaid Medicare debt. Whether the provision addresses a provider that files bankruptcy and what the implications of bankruptcy may be have not been addressed.

What is clear is that CMS intends to use the Medicare enrollment process as an enforcement tool.

Lisa English Hinkle

Lisa English Hinkle is a Member of McBrayer, McGinnis, Leslie & Kirkland, PLLC.  Ms. Hinkle concentrates her practice area in health care law and is located in the firm’s Lexington office.  She can be reached at lhinkle@mmlk.com or at (859) 231-8780. 

This article is intended as a summary of federal and state law and does not constitute legal advice.

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