New Medicare Provider Enrollment Requirements May Change the Game

The following article is about new requirements for enrollment in the Medicare and Medicaid Programs.

Please do not hesitate to contact us with comments, questions, or requests for additional information.
Elizabeth E. Hogue, Esq.
(877) 871-4062
The Centers for Medicare and Medicaid Services (CMS) announced major changes to requirements for provider enrollment effective on November 4, 2019. These changes allow CMS to revoke healthcare providers or suppliers' Medicare/Medicaid enrollment if they are affiliated with “bad actors” and pose an undue risk of fraud, waste or abuse based on their relationships with other sanctioned providers. The notice of the final rule implementing these changes appeared in the Federal Register on September 10, 2019.
CMS initially proposed requiring affiliation disclosures from all providers on both initial and revalidation enrollment applications.  In MLN Matters Number SE21003 issued on March 24, 2021, however, CMS says that it has decided to adopt a “phased-in” approach to requirements to disclose affiliations. This means that CMS will issue requests for affiliation disclosures on a discretionary basis when CMS becomes aware from any source that providers likely have at least one potentially problematic affiliation.
Practically speaking, however, CMS will not request disclosures until the Form CMS-855 applications have been updated to include disclosures of affiliations. In light of the pandemic and various other factors, CMS will not begin updating the Forms for at least another twelve months. That means that providers can, at least for the moment, heave a sigh of relief!
As of the effective date, however, Medicare and Medicaid providers will be required to disclose current or past affiliations for the previous five years with currently or formerly enrolled Medicare and Medicaid providers with disclosable events, including:
  • A current uncollected debt
  • A payment suspension under a federal healthcare program, regardless of when the suspension occurred
  • Exclusion from either the Medicare and/or Medicaid Programs
  • Denial, revocation or termination of Medicare and/or Medicaid enrollment
Types of affiliations that must be disclosed include:
  • A 5% or greater direct or indirect ownership interest
  • A general or limited partnership interest regardless of the percentage
  • 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, either under contract or through some other arrangement
  • An interest in which an individual is acting as an officer or director of a corporation
  • Any reassignment relationship
The likely consequence of these new disclosure requirements when fully implemented is that some managers, owners and directors will become unemployable in the healthcare industry because of their past affiliations. As a result of these rules, it now matters with whom providers have associated.
In short, the consequences of these rules for providers are potentially severe. Historically, at least anecdotally, the completion of the enrollment process has not gotten the attention it deserves. Now is the time to tighten up the enrollment ship!
©2021 Elizabeth E. Hogue, Esq. All rights reserved.
No portion of this material may be reproduced in any form without the advance written permission of the author.


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