Tag Archives: Enrollment

GAO Examines Medicare Provider Eligibility Verification Safeguards

The Government Accountability Office (GAO) has issued a report examining the extent to which CMS’s enrollment screening procedures are designed and implemented to prevent enrollment of ineligible or potentially fraudulent Medicare providers. The GAO identified weaknesses in CMS’s verification of provider practice location and physician licensure status that have allowed potentially ineligible providers and suppliers to … Continue Reading

CMS Again Extends Moratoria on Enrollment of HHAs, Ambulance Suppliers in Designated Areas

CMS has announced another 6-month extension of its current temporary enrollment moratoria for new ground ambulance suppliers and home health agencies (HHAs), subunits, and branch locations in designated metropolitan areas. The moratoria, which affect enrollment in Medicare, Medicaid, and the Children’s Health Insurance Program, apply to: New ground ambulances in the Houston and Philadelphia metropolitan … Continue Reading

CMS Announces New 6-Month Extension of Moratoria on Enrollment of HHAs, Ambulance Suppliers in Designated Areas

CMS is extending — for another 6 months — its current enrollment moratoria for new ground ambulance suppliers and home health agencies (HHAs) in designated metropolitan areas. The moratoria, which affect enrollment in Medicare, Medicaid, and the Children’s Health Insurance Program, apply to new ground ambulances in the Houston and Philadelphia metropolitan areas and new HHAs … Continue Reading

CMS Finalizes Rule to Strengthen Medicare Provider Enrollment Regulations and Permit Revocations for Patterns/Practices of Improper Claims Submissions; Defers Expanded Awards for Medicare Fraud Tipsters

On December 5, 2014, the Centers for Medicare & Medicaid Services (CMS) published a final rule that expands the circumstances under which it may deny or revoke the Medicare enrollment of entities and individuals on program integrity grounds, effective February 3, 2015. Among other things, the final rule: allows CMS to deny enrollment to providers, suppliers, and owners that previously were affiliated with an entity with unpaid Medicare debt; allows CMS to deny or revoke enrollment if a managing employee has been convicted of certain felony offenses; and enables CMS to revoke Medicare billing privileges for a "pattern or practice" of improper claims submissions. CMS is not finalizing its proposal to dramatically increase the potential reward for individuals who provide tips leading to the recovery of Medicare funds.… Continue Reading

CMS Delaying Enforcement of Medicare Part D Drug Prescriber Enrollment Requirements

CMS has announced that it is delaying a provision of its 2015 Medicare Advantage/Medicare Part D final rule, published on May 23, 2014, that requires physicians and other eligible professionals who prescribe Part D drugs to be enrolled in Medicare (or have a valid opt-out affidavit on file) for their prescriptions to be covered under … Continue Reading

CMS Announces 2015 Provider Enrollment Application Fee Amount

Today CMS published a notice announcing that the CY 2015 provider enrollment application fee is $553, up from $542 in 2014. This application fee is required for institutional providers that are initially enrolling or revalidating enrollment in the Medicare or Medicaid program or the Children’s Health Insurance Program (CHIP) or adding a new Medicare practice … Continue Reading

CMS Fingerprint-Based Background Checks are Underway – Impacting “High-Risk” Providers and Suppliers

CMS’s long-awaited fingerprint-based background check screening process is underway for certain “high-risk” providers and suppliers participating in federal health care programs (specifically, Medicare, Medicaid, and the Children’s Health Insurance Program). Under CMS regulations, individuals who maintain a 5 percent or greater direct or indirect ownership interest in a provider or supplier in the high risk category — … Continue Reading

CMS Again Extends Moratoria on Enrollment of HHAs, Ambulance Suppliers in Designated Areas

CMS has announced that it is extending for an additional 6 months its current enrollment moratoria for new ground ambulance suppliers and home health agencies (HHAs)within designated metropolitan areas. The moratoria, which affect enrollment in Medicare, Medicaid, and the Children’s Health Insurance Program, apply to new ground ambulances in the Houston and Philadelphia metropolitan areas and … Continue Reading

CMS to Implement Fingerprint-Based Background Checks for High-Risk Providers and Suppliers in 2014

More than three years after publication of final regulations to implement Affordable Care Act (ACA) provisions that strengthen provider and supplier enrollment screening provisions under federal health care programs, the Centers for Medicare & Medicaid Services (CMS) has selected a Fingerprint-Based Background Check Contractor and intends to phase in fingerprint-based background checks beginning in 2014.… Continue Reading

Obama Administration Cites Record-Breaking Health Fraud Recoveries under Joint DOJ-HHS Program

According to the latest Health Care Fraud and Abuse Control Program (HCFAC) Annual Report, federal health care fraud prevention and enforcement efforts resulted in the recovery of a record $4.3 billion in FY 2013, up from $4.2 billion in FY 2012. In announcing detailed enforcement achievements, the Administration cites new ACA authorities – including enhanced … Continue Reading

CMS Extends and Expands Moratoria on Enrollment of Home Health Agency, Ambulance Suppliers in Designated Areas

Citing significant potential for fraud and abuse, CMS has announced that it is temporarily suspending new home health agency (HHA) and ground ambulance enrollment in Medicare, Medicaid, and the Children’s Health Insurance Program in several geographic areas, and it is extending the current enrollment moratoria for these provider types in separate areas. Specifically, effective January … Continue Reading

CMS Boosts Provider Enrollment Fee for 2014

CMS has announced the 2014 application fee for institutional providers that are initially enrolling in the Medicare or Medicaid program or the Children’s Health Insurance Program (CHIP); revalidating their Medicare, Medicaid or CHIP enrollment; or adding a new Medicare practice location (unless a hardship exemption applies). The fee for 2014 is $542, up from $532 in … Continue Reading

CMS “Phase 2″ Ordering/Referral Denial Edits to Go Live on Jan. 6, 2014

Despite continuing provider concerns, CMS has announced that it will direct Medicare administrative contractors (MACs) to activate controversial “phase 2” ordering/referral edits effective January 6, 2014. Once activated, MACs will deny claims for Medicare Part B services (including lab services and the technical component of imaging services), durable medical equipment, and Part A home health … Continue Reading

CMS Call to Discuss Streamlined Access to PECOS, EHR, and NPPES (Nov. 15)

On November 15, 2013, CMS is hosting a provider call to discuss recent changes in the way providers and suppliers access the Provider Enrollment Chain and Ownership System (PECOS), the Electronic Health Records (EHR) Incentive Program, and the National Plan and Provider Enumeration System (NPPES).   These updates are intended to facilitate registration as an individual … Continue Reading

OIG Highlights Inaccuracy in Medicare Enrollment Databases

According to the OIG, Medicare provider enrollment databases include inaccurate, incomplete, and inconsistent provider data, and — coupled with insufficient oversight — “present vulnerabilities in all health care programs.” The OIG reviewed heath care provider information maintained in the National Plan and Provider Enumeration System (NPPES) and the Provider Enrollment, Chain and Ownership System (PECOS). … Continue Reading

CMS Delays Phase 2 Ordering and Referring Denial Edits

On April 25, 2013, CMS announced that, due to technical issues, it is delaying implementation of the Phase 2 ordering and referring denial edits until further notice. By way of background, CMS plans to implement edits that will deny claims for Medicare Part B services (including the technical/non-interpretation component of imaging services, lab services, and durable … Continue Reading

Proposed Rule Would Reward Medicare Fraud Tipsters up to $9.9 Million, Revise Medicare Provider Enrollment Regulations

This post was written by Scot T. Hasselman, Andrew C. Bernasconi, Susan A. Edwards and Debra A. McCurdy. Yesterday the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would dramatically increase the potential reward to an individual who provides a tip leading to the recovery of Medicare funds from a current … Continue Reading

Implementation of Medicare Ordering/Referring Provider Edits (March 20 Call)

Effective May 1, 2013, Medicare contractors will activate edits that will deny claims for Medicare Part B (including imaging and lab services), DME, and Part A home health agency (HHA) services if the ordering/referring physician or other professional is not identified, is not in Medicare’s enrollment records, or is not of a specialty type that may … Continue Reading

2013 Medicare Participation Enrollment Period for DMEPOS Suppliers Extended until April 15, 2013

CMS is extending the 2013 Medicare participation enrollment period for suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) until April 15, 2013. By way of background, a supplier that signs a participation agreement commits to accepting the Medicare Part B rate as payment in full for all beneficiaries. Changes in a supplier’s participation … Continue Reading

CMS Issues Revised CMS-855S, 855O Medicare Enrollment Applications

CMS has released the revised CMS-855S Medicare supplier enrollment application, version 01/13. Suppliers may use the 07/11 version of the CMS-855S through May 7, 2013, at which time any information received on the obsolete form will be returned to the supplier, according to the National Supplier Clearinghouse. CMS also has posted an updated (1/13) version of … Continue Reading

Obama Administration’s Regulatory Agenda Points to Busy 2013 for HHS

On January 8, 2013, the Obama Administration published its latest semiannual regulatory agenda, outlining planned regulatory initiatives in a number of policy areas. The Federal Register version of the agenda includes only a portion of the regulations in the pipeline, however; the full agenda has been posted on the Office of Management and Budget (OMB) web … Continue Reading

CMS Announces 2013 Provider Enrollment Application Fee Amount

CMS recently published a notice announcing a $532.00 calendar year 2013 application fee for institutional providers that are initially enrolling in the Medicare or Medicaid program or the Children’s Health Insurance Program (CHIP); revalidating their Medicare, Medicaid or CHIP enrollment; or adding a new Medicare practice location. This fee is required with any enrollment application … Continue Reading

CMS Releases Medicare Advantage/Part D Drug Plan Quality Data as Open Enrollment Period Begins

The 2013 Medicare Open Enrollment Period runs from October 15 to December 7, 2012. To help beneficiaries make informed choices, CMS has posted updated quality rating information for Medicare Advantage plans and Part D prescription drug plans for the coming year. An HHS press release summarizing the data and providing links to additional information is … Continue Reading
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