New CMS Final Rule Strengthens Enforcement Authorities To Bolster Fraud and Abuse Prevention

On September 5, 2019, the Centers for Medicare and Medicaid Services (“CMS”) issued a final rule that strengthens a number of enforcement measures.  The new rules go into effect beginning November 4, 2019.  The goal for CMS is to keep those providers and suppliers that have committed fraud out of the federal healthcare programs.

For one, the new final rules provide CMS with new revocation and denial authorities, as part of the Provider Enrollment Process, for “affiliations” that pose an undue risk of fraud, waste or abuse. Under this “affiliation” authority, a provider may be denied enrollment in Medicare, Medicaid or CHIP, if the provider has an owner or managing employee who is affiliated with another previously revoked organization.

Secondly, the new rules allow CMS to revoke or deny Medicare enrollment to providers/suppliers if:

  • Circumventing, or trying to circumvent, the previous revocation by reenrolling in the federal health care programs under a different name;
  • seeking reimbursement for services/items performed at a non-compliant location;
  • exhibiting a pattern or practice of abusive ordering or certifying of items, services or drugs paid for by Medicare;
  • maintaining an outstanding overpayment debt owed to CMS that was referred to the Treasury Department.

Further, the new rules allow CMS to prevent applicants from enrolling in the federal programs for up to three (3) years if the enrollee supplied false or misleading information in the initial enrollment application.

Finally, the rules extend the reenrollment ban for fraudulent providers from three (3) years to up to ten (10) years.  And if the provider/supplier is revoked from Medicare twice, CMS can block them from re-entering the program for up to twenty (20) years.