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CMS Issues New Reporting Requirements for Providers and Suppliers

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CMS Issues New Reporting Requirements for Providers and Suppliers

Authored by David Padalino

On September 10, 2019, the Center for Medicare & Medicaid Services (“CMS”) announced its Final Rule applying new reporting requirements for enrolled, and prospective, providers and suppliers. Medicare, Medicaid, and CHIP providers and suppliers will need to disclose their affiliations with organizations that have uncollected debts, are subject to a payment suspension under a federal health care program, have been excluded by the OIG, or had their Medicare, Medicaid, or CHIP billing privileges denied or revoked (“Disclosable Events”).

Based on the affiliations reported, CMS will determine whether the provider or supplier poses an “undue risk” of fraud, waste, or abuse. CMS may then deny or revoke Medicare enrollment, including all of the provider’s or supplier’s practice locations, regardless of whether they are a part of the same enrollment.

CMS will consider various relationships to be “affiliations” to allow CMS to retain “flexibility” in determining potential risks of fraud, waste, or abuse. The following will be considered “affiliations:”

  • A 5 percent or greater direct or indirect ownership interest that an individual or entity has in another organization;
  • A general or limited partnership interest (regardless of the percentage) that an individual or entity has in another organization;
  • An interest in which an individual or entity exercises operational or managerial control over, or directly or indirectly conducts, the day-to-day operations of another organization (including, for purposes of 42 CFR § 424.519 only, sole proprietorships), either under contract or through some other arrangement, regardless of whether or not the managing individual or entity is a W–2 employee of the organization;
  • An interest in which an individual is acting as an officer or director of a corporation; and
  • Any reassignment relationship under 42 CFR § 424.80.

CMS will use a 5-year look-back period to determine whether an “affiliation” exists. But once an “affiliation” is established, there is no cut-off for a Disclosable Event’s look-back period.

The Final Rule will also change the reenrollment bar for providers or suppliers who have their billing privileges revoked. Currently the reenrollment bar lasts for no more than 3 years, but the Final Rule would extend that maximum to a 10-year period. CMS will also impose a 20-year reenrollment bar for providers or suppliers that are revoked a second time.

Effective November 4, 2019, the Final Rule will take a proactive, rather than reactive, approach to combat waste in the federal healthcare payment system. Enrolled or prospective providers and suppliers will need to evaluate any potential affiliations that could trigger this heightened CMS scrutiny.

Link to the Final Rule: Here

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