Medicare Compliance & Reimbursement

Burden on provider to prove patient hardship.

A new proposal might play a big role in saving doctors from a harsh HHS Office of Inspector General ruling.

The Centers for Medicare and Medicaid Services published a proposed rule in the Aug. 4 Federal Register that allows the agency to ask the OIG to waive a Medicare program exclusion on behalf of a provider. CMS is seeking public comments until Oct. 3, 2005 to fill in many of the details in the proposed rule.

To benefit from CMS' mercy, a physician would have to prove that the exclusion from Medicare would place a hardship on area beneficiaries. And the physician would have to submit a copy of the OIG's exclusion notice and a request that CMS present an exclusion waiver request to the OIG.

Lastly, the doctor would have to provide documentation showing he is the sole community physician or sole source of essential specialized services in the community.

CMS may contact a provider's Quality Improvement Organization, private health insurers and others to validate facts and collect further information to support a claim of hardship.

Read the proposed rule at http://a257.g.akamaitech.net/7/257/2422/01jan20051800/edocket.access.gpo.gov/2005/pdf/05-15291.pdf.