Medicare Compliance & Reimbursement

New regs would charge you for your trouble.

Your Medicare payments are poised to come with a lot more strings if a new proposed regulation is finalized as-is. In the Patient Protection Affordable Care Act, the health care reform law enacted in March, Congress approved a number of new fraud- and abuse-fighting provisions. Now the Centers for Medicare & Medicaid Services has proposed the regulations for the mandates.

"These proposed regulations and the new tools granted to enforcers in them represent enhanced commitment to fight fraud and abuse," notes Washington, D.C.-based attorney Elizabeth Hogue. The regs aim to work "by controlling who participates in the programs and who is allowed to remain in the programs."

Increased Medicare Screening Adds Costs

One big change will be in beefing up Medicare screening both for new applicants and providers revalidating their enrollment. Under the proposed screening procedures that would take effect in 2011, Medicare providers would be categorized on three risk levels: "limited," "moderate," and "high." Providers in each risk level would be subject to increasingly aggressive screening measures, CMS explains in the proposed rule published in the Sept. 23 Federal Register.

The "limited" group would get the usual verification of Medicare requirements, license verifications, and checks of databases such as the HHS Office of Inspector General exclusions database and tax records. The "moderate" group would have unscheduled or unannounced site visits on top of the basic requirements. Finally, the "high" risk group would also undergo criminal background checks and fingerprinting.

Publicly traded companies would go into the limited risk group, while all hospices and existing home health agencies and durable medical equipment suppliers would be in the moderate group, CMS says in the rule. Newly enrolling HHAs and suppliers would go into the high-risk group.

Your two cents: CMS is soliciting comments on criteria to use to bump providers up or down in risk categories. All comments on the regs are due Nov. 16.

It may seem ironic that publicly traded companies like the ones currently under investigation by the Senate, Department of Justice, and Securities and Exchange Commission for therapy provision improprieties would go into the lowest-risk group.

"The publicly traded companies are the ones who are currently under investigation, why do they get lesser scrutiny?" asks attorney Robert Markette Jr. with Gilliland & Markette in Indianapolis.

"It is difficult to understand what seem like exceptions for publicly traded companies in view of recent activity," Hogue allows.

But these new regulations are aimed more at catching out-andout fraudsters, not providers accused of gaming the system to increase profitability, Markette points out. And remember that "the jury is definitely still out on whether there is any problem with any of the publicly held companies subject to various inquiries," Hogue adds.

New fee: CMS also proposes including a $500 user fee to pay for the increased screening. The fee, which would be updated periodically for inflation, would apply to both initial applications and revalidations.

The National Association for Home Care & Hospice

"considers the proposal to be a step in the right direction," the trade group says. "However, the focus of the screening (site visits and criminal background checks) can be expected to be of limited  value," NAHC cautions. "It will likely only detect blatant fraud and uncover hardened criminals as provider applicants."