CMS Gets Tough With Scam Artists
Written by Editor   
Wednesday, December 10, 2014 01:53 PM

In a crackdown on "bad actors," the Centers for Medicare & Medicaid Services (CMS) has revised its provider and supplier enrollment process to make it harder for unscrupulous individuals to defraud the Medicare program.

Among other things, the agency now has the ability to deny the enrollment of providers, suppliers, and owners affiliated with an entity that has unpaid Medicare debt, often as a result of not returning overpayments to CMS.

The agency cites a study by the Office of Inspector General in the Department of Health and Human Services. The Office of Inspector General found that in a random sample of durable medical equipment suppliers in Texas, each had Medicare debt of at least $50,000 that CMS deemed "currently not collectible" during 2005 and 2006. Six of the ten reviewed suppliers were associated with 15 other durable medical equipment vendors or home health agencies that received Medicare payments totaling $58 million from 2002 through 2007.

The new rules also enable CMS to deny the enrollment of a provider or a supplier if a "managing employee" of that entity has been convicted of certain felony offenses within the previous 10 years. These include "a malpractice suit that results in a conviction of criminal neglect or misconduct."

The final rule authorizes CMS to revoke billing privileges of providers and suppliers "that have a pattern of billing for services that do not meet Medicare requirements," according to a CMS fact sheet. Among the factors that CMS will consider in construing such a pattern are:

  • the percentage of submitted claims that were denied,

  • the total number of claims that were denied,

  • the reason or reasons for the claim denials,

  • whether the provider or supplier has any history of "final adverse actions,"

  • the length of time over which the pattern has continued, and

  • how long the provider or supplier has been enrolled in Medicare.

"CMS has removed nearly 25,000 providers from Medicare, and the new rules help us stop bad actors from coming back in as we continue to protect our patients. For years, some providers tried to game the system and dodge rules to get Medicare dollars; today, this final rule makes it much harder for bad actors that were removed from the program to come back in.”