COMPLIANCE | CMS Spotlight on Program Integrity and Provider Enrollment in Medicare, Medicaid, and CHIP

By Carrie Kovar

This article is a part of the November/December 2019, Volume 31, Number 6, Audiology Today issue.

The Centers for Medicare and Medicaid Services (CMS) recently issued a final rule that provides more authority for CMS to address fraud, waste, and abuse in federal health insurance programs including Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). The new rule aims to bolster the ability of CMS to fight fraudulent or other inappropriate activity before it happens and before providers are paid.

Known as the “Program Integrity Enhancements to the Provider Enrollment Process” (CMS-6058-FC), this final regulation, effective November 4, 2019, creates several new revocation and denial authorities to allow CMS to block providers from program participation.

Importantly, a new affiliations authority will allow CMS to deny or revoke provider enrollment under Medicare, Medicaid, and CHIP because of affiliation with an individual or entity previously revoked or sanctioned.

CMS provides as an example: “A currently enrolled or newly enrolling organization that has an owner/managing employee who is ‘affiliated’ with another previously revoked organization can be denied enrollment in Medicare, Medicaid, and CHIP or, if already enrolled, can have its enrollment revoked because of the problematic affiliation.”

Specifically, providers and suppliers must disclose any current or previous direct or indirect affiliation with a provider or supplier that: (1) has uncollected debt; (2) has been, or is subject to, a payment suspension under a federal health-care program; (3) has been, or is, excluded by the Office of Inspector General (OIG) from Medicare, Medicaid, or CHIP; or (4) has had its Medicare, Medicaid, or CHIP billing privileges denied or revoked.