The Centers for Medicare & Medicaid Services is tightening scrutiny of providers enrolling in Medicare in an effort to curb fraudulent billing and keep providers with unpaid Medicare debt from reentering the program.

New rules announced Dec. 3 by the CMS strengthen the agency’s ability to deny or revoke the enrollment of entities and individuals believed to pose a program integrity risk to Medicare. The regulations come after the February 2011 revision of CMS’s enrollment policy, a revamp aimed at increasing the integrity of Medicare. Under the Dec. 3 enrollment provisions, the CMS can now:

• Deny the enrollment of providers, suppliers, and owners affiliated with an entity that has unpaid Medicare debt (existing overpayment or another form of financial obligation).

• Deny the enrollment or revoke the billing privileges of a provider or supplier if a managing employee has been convicted of certain felonies (murder, rape, assault, extortion, embezzlement, income tax evasion).

• Revoke the billing privileges of providers and suppliers who have a pattern or practice of billing for services that do not meet Medicare requirements.

The new rules will prevent individuals and entities from being able to incur substantial debt to Medicare, leave the Medicare program, and then reenroll as a new business to avoid repayment of the outstanding Medicare debt, according to the agency.

Physicians and other prospective enrollees who owe Medicare money can avoid being denied by agreeing to a CMS-approved extended repayment schedule for the entire outstanding Medicare debt or by repaying it in full.

In its final rule, the CMS acknowledged that the majority of Medicare provider enrollees submit valid claims that meet the CMS guidelines.

“A small percentage of providers and suppliers are engaging in fraudulent, wasteful, inappropriate, or abusive activities,” the agency wrote in the Federal Register. “Our provider enrollment revisions are directed at such providers and suppliers, and we believe that removing them, as necessary, from the Medicare program will only serve to benefit Medicare beneficiaries, the trust funds, the taxpayers, and the hundreds of thousands of legitimate Medicare providers and suppliers that have proven to be reliable partners of the program.”

The final rules will be published in the Federal Register Dec. 5. A preliminary version of the regulations is available on the Federal Register website.

agallegos@frontlinemedcom.com

On Twitter @legal_med

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