CMS Issues New Regulations to Enhance Program Integrity

The U.S. Department of Health and Human Services (HHS), Centers for Medicare and Medicaid Services (CMS), published a final rule in the September 10, 2019 Federal Register to implement program integrity enhancements to the provider enrollment process under Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP).  The CMS rule will be effective November 4, 2019.

The new rule will require providers under CMS programs to disclose, as part of the enrollment and re-enrollment process, any current or previous affiliation with any other provider that:

  • Has uncollected debts related to CMS programs,
  • Has been subject to a payment suspension,
  • Has been excluded from CMS programs by the HHS Office of the Inspector General (OIG), or
  • Has had its Medicare, Medicaid, or CHIP billing privileges denied or revoked.

CMS will use this information to deny providers Medicare enrollment in cases where the provider’s affiliations—such as elements of common ownership and control—indicate an undue risk of fraud and program abuse. While such information does not automatically preclude providers from furnishing services under Medicaid and CHIP, states will also be able to use the information to achieve greater program integrity in the Medicaid and CHIP provider enrollment process.

With the final rule’s effective date on the horizon, state Medicaid programs and provider organizations must evaluate how they will track and report their affiliations and identify cost-effective compliance solutions under these new regulations.

Comment Period

CMS will accept comments on several provisions of the new regulations until November 4, 2019.  The new regulations are available in the Federal Register here.

Additional background information from CMS on the new regulations is available here.

Leave a Reply

%d bloggers like this: