New Medicare Rules Strengthen Regulatory Oversight of Medicare Providers and Increase CMS’ Ability to Remove Providers from Medicare

united-states-capital-516992-m.jpgEarlier this month, the Centers for Medicare and Medicaid Services (CMS) announced implementation of a Final Rule intended to increase oversight of Medicare providers and enable recoveries from those health care providers that commit fraud and violate Medicare rules. According to the press release, Marilyn Tavenner, the CMS Administrator, stated that the new rules “are common-sense safeguards to preserve Medicare for generations to come” and that “[t]he Administration is committed to using all appropriate tools as part of its comprehensive program integrity strategy shaped by the Affordable Care Act [ACA].”

Georgia Medicare Fraud Law Firm

Our Atlanta and Augusta, Georgia health care law firm has reviewed the Final Rule. The Final Rule’s new provisions are intended to preclude doctors and other health care providers with unpaid Medicare debt from re-entering the Medicare program, remove health care providers who engage in abusive Medicare billing, and authorize other provisions that will save more than $327 million annually. The Final Rule makes certain changes to the provider enrollment provisions of 42 CFR part 424, subpart P.

CMS has removed about 25,000 health care providers from the Medicare program. The new rules are designed to “stop bad actors from coming back in as we continue to protect our patients,” according to Ms. Tavenner. Under the ACA, CMS has increased ability to fight Medicare fraud, waste and abuse. CMS believes that removing providers from Medicare has a substantial positive impact on savings, contending that such removals have prevented $81 million in payments from being made.

According to CMS, the new Medicare rules do the following, among other things:

  • Provide CMS the ability to prevent providers, suppliers, and owners affiliated with an entity that has unpaid Medicare debt from being enrolled in Medicare. This rule is designed to preclude providers from incurring substantial Medicare debt, then leaving the program and re-enrolling as a new business to avoid repayment of the outstanding Medicare debt. Under the changed rule, CMS will only enroll otherwise eligible providers if such debts are paid.
  • Allow CMS to prevent or revoke billing privileges of a provider if the provider has a managing employee who has been convicted of certain felony offenses.
  • Authorize CMS to revoke billing privileges of providers who engage in patterns of billing for services that fail to meet CMS standards or requirements.
  • Making the effective date of billing privileges consistent across certain provider and supplier types.

CMS and federal law enforcement agencies continue to target health care fraud as a top priority. Health care fraud is a major source of financial strain for the federal government and the federal tax payer. Unfortunately, the regulatory environment that has developed to address the potential for bad actors also creates substantial hardship for most health care providers and businesses who are required to know and follow the increasingly complex rules and regulations that govern the health care industry.

Our Atlanta and Augusta, Georgia law firm represents physician practices and other health care professionals and businesses. If you have questions about this blog post or any health care legal issue, contact us at (404) 685-1662 (Atlanta) or (706) 722-7886 (Augusta), or by email.

Press Release
Final Rule

Disclaimer: Thoughts shared here do not constitute legal advice. Please consult with an attorney to discuss your legal issue.

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