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
Enrollment
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…
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…
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…
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…
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).
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…
Proposed Rule Would Reward Medicare Fraud Tipsters up to $9.9 Million, Revise Medicare Provider Enrollment Regulations
This post was also written by Andrew C. Bernasconi.
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 maximum of $1,000 to a maximum of $9.9 million under the Medicare Incentive Reward Program. Since 1998, an individual providing information regarding potential Medicare fraud and abuse to the Department of Health & Human Services’ Office of Inspector General or the Medicare contractor with jurisdiction over the suspected fraudulent provider or supplier may be eligible to receive 10 percent of the Medicare funds ultimately collected from the tip, or $1,000, whichever is less. Pursuant to the proposed rule CMS issued yesterday, an individual furnishing information that otherwise satisfies the requirements set forth in 42 C.F.R. § 420.405 would be eligible to receive 15 percent of a recovery up to $66 million. Therefore, a tipster could receive up to a $9.9 million reward for any information provided regarding suspected Medicare fraud and abuse.Continue Reading Proposed Rule Would Reward Medicare Fraud Tipsters up to $9.9 Million, Revise Medicare Provider Enrollment Regulations
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…
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…
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…
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 site. Major Department of Health and Human Services (HHS) regulations are highlighted after the jump.Continue Reading Obama Administration’s Regulatory Agenda Points to Busy 2013 for HHS
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…
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.
CMS Call on Medicare Provider Enrollment (Oct. 10)
On October 10, 2012, CMS will hold a National Provider Call on Medicare Provider Enrollment. The call will cover the following topics: Revalidation; Billing for Ordered/Referred Services; and PECOS Enhancements. Registration is required.
CMS Proposes Revisions to DMEPOS Supplier Application
CMS is proposing changes to the Medicare enrollment application for DMEPOS suppliers (CMS 855S) to simplify and clarify the current data collection and to remove obsolete questions. According to CMS, the majority of the revisions are non-substantive in nature (e.g., spelling and formatting corrections). Comments on the forms will be accepted until June 4, 2012.
GAO Reviews Medicare Provider/Supplier Screening Efforts
The GAO has issued a report entitled “Medicare Program Integrity: CMS Continues Efforts to Strengthen the Screening of Providers and Suppliers.” The GAO describes how CMS and its contractors use provider and supplier enrollment information to prevent improper payments, along with factors that may affect the usefulness of this information. The report also…
CMS Finalizes Changes in Medicare/Medicaid Provider and Supplier Enrollment, Ordering, Documentation Requirements
CMS published a final rule on April 27, 2012 that updates regulations regarding Medicare and Medicaid provider and supplier enrollment, ordering and referring, documentation requirements, and provider agreements, effective June 26, 2012. The rule modifies and finalizes several ACA provisions implemented in the May 5, 2010 interim final rule with comment period. Among other…
CMS Upgrades to PECOS Enrollment System
CMS has announced a series of upgrades to the Medicare online enrollment system, known as PECOS (“Provider Enrollment, Chain, and Ownership System”), that are intended to reduce data entry time and increase access to information.
CMS Hosts Orlando Symposium on Empowering Minorities (Dec. 14-16)
The CMS Atlanta Regional Office is hosting a symposium in Orlando, Florida on December 14 -16, 2011 entitled “Empowering Minorities — Promoting Better Health, Better Care, Lower Cost for Medicare Beneficiaries in their Communities.” The symposium will feature speakers, panels, and breakout sessions covering a wide range of topics such as Medicare Fraud…