New fraud prevention rule gives CMS greater discretion

Providers should read between the lines in order to understand how CMS will punish "bad actors"

Last week, the Centers for Medicare & Medicaid Services (CMS) issued a final rule focusing on new safeguards to reduce Medicare fraud. The new rule gives CMS the "ability to deny or revoke the enrollment of entities and individuals that pose a program integrity risk to Medicare."

George B. Breen--a lawyer in the Health Care and Life Sciences and Litigation practices at Epstein Becker Green in the District of Columbia, and chair of the firm's National Health Care and Life Sciences Practice Steering Committee--said he's not surprised that CMS is putting resources towards this specific area of fraud prevention, considering the tremendous focus that the government has already put towards healthcare fraud enforcement.

"It really gives CMS some additional tools to keep what it considers bad actors or potentially bad actors out of the system," Breen (pictured right) said in an interview with FierceHealthPayer: AntiFraud. "This, again, is consistent with what CMS has done recently."

Keep "bad actors" out

Specifically, CMS aims to prevent "bad actors" from matriculating back into the system by instituting changes that allow CMS to do the following:

  • Deny enrollment to providers, suppliers and owners affiliated with any entity that has unpaid Medicare debt.

  • Deny or revoke the enrollment of a provider or supplier if a managing employee has been convicted of a felony offense that CMS determines to be detrimental to Medicare beneficiaries.

  • Revoke enrollments of providers and suppliers engaging in abuse of billing privileges by demonstrating a pattern or practice of billing that do not meet Medicare requirements.

"CMS has removed nearly 25,000 providers from Medicare and the new rules help us stop bad actors from coming back in as we continue to protect our patients," Shantanu Agrawal, M.D., CMS deputy administrator and director of the Center for Program Integrity, said in a statement. "For years, some providers tried to game the system and dodge rules to get Medicare dollars; today, this final rule makes it much harder for bad actors that were removed from the program to come back in."