CMS issues rule to stop Medicare fraud: 5 things to know

Morgan Haefner - Print  | 

CMS released a final rule Sept. 5 that creates several new efforts to address Medicare and Medicaid fraud.

Five things to know:

1. Effective Nov. 4, the final rule outlines new authorities for CMS. The agency can now identify healthcare providers and suppliers who may be at risk of committing fraud based on their relationships with other organizations who have been sanctioned for fraud.

2. Under the final rule, an organization enrolled in the federal Medicare and Medicaid programs can be denied participation in Medicare if its owner or a managing employee is affiliated with another previously sanctioned organization. If the organization is already enrolled and such a relationship is identified, it could lose its Medicare and Medicaid billing privileges.

3. CMS will also revoke or deny Medicare enrollment to a provider or supplier who reenters the program under a different name, bills for services from noncompliant locations, shows questionable ordering or certifying patterns of services and drugs, or owes CMS reimbursement for overpayments.

4. If a provider submits false claims or includes misleading information in its enrollment application, CMS can now bar the provider from enrolling in Medicare or Medicaid for up to three years.

5. In addition, CMS can now block providers and suppliers who are revoked from reentering the Medicare program for up to a decade. If a provider is revoked from the program a second time, CMS can bar the provider from participating in the programs for up to 20 years.

Read more here.

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