Medicare requires practices to look back further for sanctioned persons or related affiliates

Effective November 4, 2019, the Centers for Medicare & Medicaid Services (CMS) will implement its 2019 final rule to address fraud and other vulnerabilities in the CMS Medicare and Medicaid programs.

This new rule requires Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) providers and suppliers to disclose any current or previous direct or indirect affiliation with a provider or supplier that (1) has uncollected debt; (2) has been or is subject to a payment suspension under a federal health care program; (3) has been or is excluded by the Office of Inspector General (OIG) from Medicare, Medicaid, or CHIP; or (4) has had its Medicare, Medicaid, or CHIP billing privileges denied or revoked.

Note that “Direct or indirect affiliation” here is contingent upon degree of ownership or managerial control consistent with other provisions of the Act.

Importantly, CMS has cast an extremely wide net with this new regulation. Practices should use the time before the implementation date to identify any and all possible affiliations of consequence.

The OIG’s List of Excluded Individuals/Entities (LEIE) online searchable database can help determine if an individual or entity is currently under federal sanction. Supplemental reinstatements are archived by the OIG only for the previous twelve months, so finding older problematic affiliations may be difficult.

At present, disclosure is not mandatory until CMS determines at least one such affiliation exists and subsequently makes a disclosure order. Nonetheless, providers and suppliers are encouraged to do their due diligence and determine the existence of any such affiliations as well as voluntarily disclose such affiliations when discovered.  The Secretary of Health and Human Services (HHS) may deny or revoke enrollment when it is determined that such an affiliation poses an undue risk of fraud, waste, or abuse. Finally, CMS increased the maximum re-enrollment bar for those who are excluded from the current 3 years to up to 10 years.

We are happy to assist providers and groups in any way with MIPS, general claims issues and other coverage topics, which include proper code selection, chart reviews, and payer action questions.  We can also provide training on these or other subjects.  You can also download our “App”, Corcoran 24/7, which can be separately accessed via one of the links below. (800) 399-6565

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