Pathology/Lab Coding Alert

New instruction may limit participation.

Don’t let “patients over paperwork” lull you into complacency about how much administrative work is required for Medicare participation moving forward.

In fact: Nipping fraud and abuse in the bud is CMS’ justification to elicit more information from you, the Medicare provider. Read on to learn how the new rule, “Program Integrity Enhancements to the Provider Enrollment Process” will impact your lab.

Focus on Rule’s Purpose

Published Sept. 10 in the Federal Register and effective Nov. 4, the new rule targets organization owners as well as providers and suppliers. Affiliated owners have previously escaped enforcement and exclusion, but CMS aims to close up that loophole.

“The new rule is intended [to] prevent bad actors from circumventing Medicare requirements by using elaborate, inter-provider relationships, or through name and identity changes,” explain Atlanta-based partner attorneys Jessica Tobin Grozine and Hedy Silver Rubinger with Arnall Golden Gregory LLP in online analysis.

According to CMS Administrator Seema Verma in a press release regarding the new rule, “Now, for the first time, we have tools to stop criminals before they can steal from taxpayers. This is CMS hardening the target for criminals and locking the door to the vault. If you’re a bad actor you can never get into the program, and you can’t steal from it.”

Know What You Must Give

Medicare providers and suppliers will now need to list all affiliations with other providers and suppliers on their enrollment applications who are currently in debt and/or are suspended, have their rights revoked, and are excluded from federal healthcare programs.

CMS extends revocation authority to look beyond a provider’s enrollment location and scrutinize more deeply past abusive and negligent behavior in all areas of Medicare.

Information about your affiliations that could prove damaging include the following:

• A provider or supplier that circumvents program rules by attempting to come back into the program under a different name
• A provider or supplier that bills for services/items from non-compliant locations
• A provider or supplier that exhibits a pattern of abusive ordering or certifying of Medicare Part A or Part B items, services or drugs
• A provider or supplier that has an outstanding debt to CMS from an overpayment that was referred to the Treasury Department.

Learn What You Might Get

Under the rule, “CMS will have authority to deny or revoke a provider’s or supplier’s Medicare enrollment in certain specified circumstances,” warns Grozine and Rubinger.

Alert: The bad actions of your affiliations could impact you. For example, “a currently enrolled or newly enrolling organization that has an owner/managing employee who is ‘affiliated’ with another previously revoked organization can be denied enrollment in Medicare, Medicaid, and CHIP or, if already enrolled, can have its enrollment revoked because of the problematic affiliation,” according to the press release.

The new enforcement authorities outlined in the rule “will work hand-in-hand with current change of ownership requirements to give CMS greater authority to deny or revoke enrollment,” say Grozine and Rubinger.

More: If a provider or supplier misleads or lies on an enrollment application, CMS may now prohibit enrollment for up to 10 years, while the limit was three years under previous rules. For a second revocation, providers and suppliers may be banned from re-entering the Medicare program for up to 20 years, according to the new rule.

Resource: You can read more at  www.cms.gov/newsroom/press-releases/cms-announces-new-enforcement-authorities-reduce-criminal-behavior-medicare-medicaid-and-chip.