New fraud prevention rule gives CMS greater discretion

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

In the same vein, the new rule lets CMS deny or revoke enrollment based on abusive billing that demonstrates "a pattern or practice of billing for services that do not meet Medicare requirements." In the final rule, CMS defines this using the following factors:

  • The percentage of submitted claims that were denied

  • The total number of claims that were denied

  • The reason(s) for the claim denials

  • Whether the provider or supplier has any history of "final adverse actions"

  • The length of time over which the pattern has continued

  • How long the provider or supplier has been enrolled in Medicare

However, CMS is not limited to these factors, Breen said.

"As someone who is concentrated on representing healthcare entities, that clearly says to me that, in a situation where an entity is being refused enrollment, there are significant opportunities to challenge that," he said. "CMS has a significant amount of discretion, so you want to put that to the test in terms of a challenge if your obligation for enrollment is rejected. But entities also need to understand that these are the factors CMS is looking at."  

Ultimately, Breen said, owners, providers and suppliers should be aware of the government's increasingly expanded focus on Medicare fraud, and of how this new rule offers CMS additional means of fraud prevention and enforcement. Read the final rule not with the notion that you suddenly have new obligations but, rather, that  there is a further assessment of what you're doing.

"You need to be sensitive to the fact that what you may have otherwise treated as a normal or routine basic request for information may in fact have a different connotation now that you have this rule," Breen said.

For more:
read the CMS statement

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