CMS Rolls Out New Powers to Target Healthcare Fraud

The announcement is all but ensured to trouble providers already concerned about overreach.

Federal healthcare oversight authorities have announced that they are expanding their “revocation and denial authorities” in an effort to enhance their efforts to fight waste, fraud, and abuse in the American healthcare system – marking a move all but guaranteed to trouble providers already concerned over perceived overreach among contracted auditing bodies.

The Centers for Medicare & Medicaid Services (CMS) announced Thursday that it has issued a final rule memorializing the move, officially titled the Program Integrity Enhancements to the Provider Enrollment Process (CMS-6058-FC), with agency officials saying it would strengthen CMS’s “ability to stop fraud before it happens by keeping unscrupulous providers out of our federal health insurance programs.”

“This first-of-its-kind action –- stopping fraudsters before they get paid –- marks a critical step forward in CMS’s longstanding fight to end ‘pay and chase’ in federal healthcare fraud efforts and replace it with smart, effective, and proactive measures,” CMS said in a press release. “Today’s action is part of the Trump Administration’s ongoing effort to safeguard taxpayer dollars and protect the core integrity of the critical Medicare and Medicaid programs that millions rely on.”

Notably, the press release indicated, a new “affiliations” authority in the final rule will allow CMS to identify individuals and organizations that “pose an undue risk of fraud, waste, or abuse, based on their relationships with other previously sanctioned entities.” An example provided was a currently enrolled or newly enrolling healthcare organization that has an owner/managing employee who is “affiliated” with another previously revoked organization – such an entity now can be denied enrollment in Medicare, Medicaid, and the federal Children’s Health Insurance Program (CHIP) or, if already enrolled, can have its enrollment revoked because of what officials described as the “problematic” affiliation.  

“For too many years, we have played an expensive and inefficient game of ‘whack-a-mole’ with criminals – going after them one at a time – as they steal from our programs. These fraudsters temporarily disappear into complex, hard-to-track webs of criminal entities, and then re-emerge under different corporate names. These criminals engage in the same behaviors again and again,” CMS Administrator Seema Verma said in a statement. “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.”

The press release laid out other similar new powers for CMS as well, noting that a basis for administrative action will now exist if:

• A provider or supplier circumvents program rules by coming back into the program, or attempting to come back in, under a different name after being excluded (e.g. the provider attempts to “reinvent” itself);
• A provider or supplier bills for services/items from non-compliant locations;
• A provider or supplier exhibits a pattern or practice of abusive ordering or certifying of Medicare Part A or Part B items, services, or drugs; or
• A provider or supplier has an outstanding debt to CMS from an overpayment that was referred to the Treasury Department.

The new rule also gives CMS the ability to prevent applicants from enrolling in the federal programs for up to three years if a provider or supplier is found to have submitted false or misleading information in its initial enrollment application. Furthermore, the new rule now will allow CMS to block providers and suppliers who are revoked from re-entering the Medicare program for up to 10 years (previously, it was three years). Additionally, if a provider or supplier is revoked from Medicare for a second time, CMS can now block that provider or supplier from re-entering the program for up to 20 years.

The changes are scheduled to take effect on Monday, Nov. 4, at which time CMS pledged it would “ensure that the only providers and suppliers that will face additional burdens are ‘bad actors,’” defined by the agency as “those who have real and demonstrable histories of conduct and relationships that pose undue risk to taxpayers, patients, and program beneficiaries.”

“This new rule ushers in an important new era of smart, effective, proactive, and risk-based tools designed to protect the integrity of these vitally important federal healthcare programs we rely on every day to care for millions of Americans,” CMS said. “This new rule builds on CMS’s previous successful efforts to protect beneficiaries and taxpayer dollars while limiting the burden on our provider partners without whom we could not deliver high-quality care to the millions of people we are honored to serve.”

“Every dollar that is stolen from federal programs is a dollar that will never contribute to paying for an item or service for seniors and eligible people who need them,” Verma added.