News: CMS to focus on stopping repeat fraud offenders

CMS announced a new rule recently, called the Program Integrity Enhancements to the Provider Enrollment Process, which will focus on catching providers before they engage in fraudulent activity. The new rule includes an “affiliations” provision which allows authorities to bar individuals and organizations from Medicare enrollment if they “pose an undue risk of fraud, waste, or abuse based on their relationships with other sanctioned entities.”

Under the rule, Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) providers will be required to disclose any current or previous affiliation with organizations that have uncollected debt, have had a payment suspension under a federal healthcare program, have been excluded from those programs, or have had billing privileges denied or rescinded, according to Modern Healthcare.

According to CMS, the new rule will take a proactive approach to fraud prevention.

“For too many years, we have played an expensive and inefficient game of ‘whack-a-mole’ with criminals—going after them one at a time—as they steal from our programs. These fraudsters temporarily disappear into complex, hard-to-track webs of criminal entities, and then re-emerge under different corporate names. These criminals engage in the same behaviors again and again,” CMS Administrator Seema Verma said in a statement. “Now, for the first time, we have tools to stop criminals before they can steal from taxpayers.”

The original version of this program was introduced in 2014, but it focused on barring providers with unpaid Medicare debts or with a managing employee that had certain felony convictions, according to Healthcare Dive. A similar update to the program was proposed in 2016, but ultimately wasn’t implemented after the American Hospital Association cautioned that it could penalize providers for minor administrative errors.

The new program is set to take effect on November 4, 2019. 

Editor’s note: To read the new rule, click here. To read Verma’s statement, click here. To read Modern Healthcare’s coverage of this story, click here. To read Healthcare Dive’s coverage of this story, click here.