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Proposed rule clamps down on providers with a history of fraud

A new rule would expand CMS's power to deny or suspend providers with fraud connections

A proposed rule released by the Centers for Medicare & Medicaid Services (CMS) would expand the power of government officials to deny or revoke billing privileges for providers that pose a risk to federal healthcare programs.

"We believe that our proposals would help make certain that entities and individuals who pose risks to the Medicare program are removed from and kept out of Medicare for extended periods of time; in particular, the rule would crack down on providers and suppliers who attempt to circumvent Medicare requirements through name and identity changes as well as through elaborate, inter-provider relationships," the rule states.

CMS could also revoke the billing privileges of a physician that demonstrates an "abusive" billing patterns and gain the authority to deny Medicare billing privileges to a provider that is barred from a state Medicaid program.

According to CMS, federal authorities would be allowed to track current and past relationships between providers and shut down schemes that rely on a network of fraudulent providers. In some instances, providers found guilty of fraud will hide behind nominee owners, and bill Medicare for millions of dollars before shutting down and opening up a new company. Under current regulations, without a felony conviction, owners can remain in the system undetected under various business names and locations.

A report last year showed thousands of doctors continued billing federal programs even after their Medicare and Medicaid billing privileges had been revoked. Investigators from the Government Accountability Office also found that four states paid nearly $3 million in 2011 to providers with a revoked license. During that same year, the Office of Inspector General found 300 banned providers continued billing Medicaid in other states for as many as three years, which the watchdog agency traced back to lack of easily accessible and comprehensive data regarding for cause terminations.

To learrn more:
- here's the proposed rule

Related Articles:
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Hearing highlights troubling gaps in Medicaid fraud prevention
The cautionary tale of Florence Bikundi, an excluded provider
Report: Banned physicians continue billing federal programs