Home Health & Hospice Week

Ramifications from Dr. Jacques Roy case seen in proposed rule.

The home care and hospice industry have often been painted with a broad fraud brush thanks to the actions of a small group of unscrupulous providers, and have called on Medicare to make entry into the program more difficult for fraudsters. Home care providers may soon see some of their wish list come true — but will it overly burden good actors too?

In a proposed rule in the March 1 Federal Register, the Centers for Medicare & Medicaid Services floats a bevy of new restrictions aimed at keeping criminals out of the provider pool. They include:

• Disclosing affiliations. The rule would require health care providers and suppliers to report affiliations with entities and individuals that: (1) currently have uncollected debt to Medicare, Medicaid, or CHIP; (2) have been or are subject to a payment suspension under a federal health care program or subject to an HHS Office of Inspector General exclusion;

or (3) have had their Medicare, Medicaid, or CHIP enrollment denied or revoked. CMS could deny or revoke the provider’s or supplier’s Medicare, Medicaid, or CHIP enrollment if CMS determines that the affiliation poses an undue risk of fraud, waste, or abuse.

• Enhancing revocation authority. Under the rule, CMS could deny or revoke Medicare enrollment under an expanded set of circumstances, including when a provider is currently revoked under a different name, numerical identifier, or business identity; and when a provider is revoked in Medicaid or another state (including under different names, etc.).
• Targeting abusive prescribing by docs. CMS would be able to revoke a physician’s enrolment if she has “a pattern or practice of ordering, certifying, referring, or prescribing Medicare Part A or B services, items, or drugs that is abusive,” CMS notes in a release.

Beware: In the infamous Dr. Jacques Roy case in Texas, home health agencies served by the “abusive” physician also saw Medicare payment suspensions solely for having a large portion of patients referred by the questionable doc, observers remind providers.

• Extending Medicare bans. The rule would increase the wait period for reenrolment from three to 10 years; allow CMS to add three years to the ban if the provider tried to reenroll early; and would permit a 20-year ban if the provider was being revoked a second time.

Medicare Uses Payment Data To Decide Visits

In a separate release, CMS highlights the tougher enrollment and screening procedures it already is putting in place to prevent fraudsters from entering Medicare. The agency is increasing its site visits; using better software and processes to verify addresses (and identify vacant ones) on an ongoing basis; and deactivating certain providers who haven’t billed in more than a year.

Targets: “CMS is now increasing site visits, initially targeting those providers and suppliers receiving high reimbursements by Medicare that are located in high-risk geographic areas,” the agency explains in the release.

“CMS believes that increasing site visits, improving IT systems, and conducting continuous data monitoring will strengthen the integrity of the Medicare program while minimizing burden on the provider community,” the agency says.

Note: The proposed rule is at www.gpo.gov/fdsys/pkg/FR-2016-03-01/pdf/2016-04312.pdf. You may submit comments on the rule until April 25.