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New Enforcement Authorities to Reduce Criminal Behavior in Medicare, Medicaid, and CHIP

Wednesday, September 18, 2019  
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CMS issued a final rule, effective Nov. 4, 2019, that strengthens the agency’s ability to stop fraud before it happens by keeping unscrupulous providers out of our federal health insurance programs. This first-of-its-kind action – stopping fraudsters before they get paid – marks a critical step forward in our longstanding fight to end “pay and chase” in federal health care fraud efforts and replace it with smart, effective, and proactive measures.

The final rule creates several new revocation and denial authorities to bolster our efforts to stop waste, fraud, and abuse. A new authority in the rule allows CMS to identify individuals and organizations that pose an undue risk based on their relationships with other previously sanctioned entities.

The rule also includes other authorities that will effectively improve our fraud-fighting capabilities. Similar to the affiliations component, these authorities provide a basis for administrative action to revoke or deny, as applicable, Medicare enrollment if a provider or supplier:

  • Circumvents program rules by coming back into the program, or attempting to come back in, under a different name
  • Bills for services/items from non-compliant locations
  • Exhibits a pattern or practice of abusive ordering or certifying of Medicare Part A or Part B items, services, or drugs
  • Has an outstanding debt to CMS from an overpayment that was referred to the Treasury Department

The new rule also gives CMS the ability to prevent applicants from enrolling in the program for up to 3 years if a provider or supplier is found to have submitted false or misleading information in its initial enrollment application. Furthermore, the new rule expands the reenrollment bar that prevents fraudulent or otherwise problematic providers from re-entering the Medicare program. CMS can now block providers and suppliers who are revoked from re-entering the Medicare program for up to 10 years. Additionally, if a provider or supplier is revoked from Medicare for a second time, CMS can now block that provider or supplier from re-entering the program for up to 20 years.

To learn more, visit the Center for Program Integrity Spotlight webpage. See the full text of this excerpted CMS Press Release, issued Sept. 5.


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