As of March 25, 2011 the new CMS provider enrollment rules are enacted.  We covered most of the proposed changes in a previous blog post so we’ll just briefly touch on them here.  The primary objective of these changes is to address and help minimize the incidents of  fraud and abuse in the Medicare program.  The new processes includes additional screening,  the suspension of payments where allegations of fraud exist and the new rules grant the CMS the authority to impose a temporary moratorium on new enrollments for particular types of practices in particular geographic areas. There are also new application fees and procedures included as part of the rules revamp.

The new screening process includes assigning providers and suppliers to one of three risk levels: limited, moderate or high.  The screening process will be more detailed and involved the higher the assigned risk category.

Non-refundable Application fees will be charged when initially enrolling in Medicare, when adding a practice location or when revalidating enrollment information.  The fee for March 25, 2011 until Dec 31, 2100 is $505. There are hardship exceptions and refunds are possible if an application is rejected during screening or a temporary moratorium has been applied.

CMS is given the right to impose a moratorium on the enrollment of new Medicare providers of a particular type in a particular geographic areas and the establishment of new practice locations of those types in said locations.  This moratorium would be in response to a high incident of fraud and abuse allegations.

As a practical matter these procedurally changes are likely to have little effect on the typical provider enrollment process.  Where they do come into play it will make the enrollment process considerably more complicated and involved.

The detailed instructions can be found here

The Health and Human Services Department along with the Justice Department have issued rules detailing several new provider enrollment procedural steps and investigative routines to help identify and prevent fraud in the Medicare, Medicaid and the Children Health Insurance Program, a key provision of the healthcare law enacted last year. The rules are designed to help these agencies act in a more proactive way to prevent and target potential improper payments. The rules are out and open for comment for the next 60 days. They can be found here

The goal of these new rules are to move those suspected of fraud off the approved vendor list more quickly and tighten the provider enrollment process to prevent high risk providers from getting approved in the first place. In addition to the rule changes, the program incorporates both improved investigative technologies and an increases in manpower.

Individual providers, geographic areas and provider specialties will be evaluate. Based upon historical trends and the level of known or suspected fraudulent activities, they will be assigned a specific risk assessment level of “Limited”, “Moderate” or “High”. Based upon that classification, a providers will undergo the following screening process as part of their enrollment process.

Proposed Screening Levels and Procedures for Medicare Physicians,Non-Physician Practitioners, Providers, and Suppliers

The major changes to the existing screening process is the addition of unscheduled site visits, criminal background checks and fingerprinting for those providers deemed to be in the Moderate or High risk categories. The vast majority of providers will of course fall within the Limited category and will see no changes to their existing provider enrollment process. State run Medicaid and CHIP programs will be encouraged to adopt the same or similar procedures.

Listen to details of the announcement click below

Anti Fraud Program Announcement