New Medicare and Medicaid Enrollment Rules Take Effect Today

Significant changes effecting Medicare- and Medicaid-enrolled providers and suppliers take effect today, March 25, 2011.  The new regulations are in response to provisions in the recent health care reform legislation designed to enhance the enrollment procedures to protect against fraud.  All Medicare-enrolled providers and suppliers were grouped into one of three categories “limited,” “moderate,” or “high” risk, with delineated enrollment screening procedures for each category.  The greater the perceived risk of fraud, the more scrutiny for the applicant or enrollee.

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60-Day Comment Period for New Medicare and Medicaid Enrollment Rules Ends November 16, 2010

Do not lose this opportunity to submit comments to the proposed changes in the Medicare and Medicaid enrollment rules, whether submitted individually or in conjunction with professional or trade associations.

Enrollment screening procedures would be increasing more rigorous based upon the provider’s or supplier’s placement into the “limited,” “moderate,” or “high” risk category.

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Site Verifications – Would Your Practice Location Pass?

As part of the overhaul of the enrollment rules in June 2006, CMS adopted new regulations under 42 C.F.R. § 424.510(d)(8) authorizing on-site reviews to determine if an enrolled provider or supplier is “operational” to furnish Medicare covered items or services and whether or not the provider or supplier is in compliance with the Medicare enrollment requirements. These site verifications are in addition to on-site surveys performed for determining compliance with the conditions of participation for Medicare-certified providers and suppliers.

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Requirement to Have a Current Approved PECOS Record

A recurring theme of this Blog will be to highlight various initiatives undertaken by CMS to tighten the Medicare enrollment rules in an attempt to combat fraud and abuse. Fueling one of the initiatives is CMS’ concern that historically providers and suppliers with questionable qualifications have been allowed to enroll in Medicare. To address this concern, CMS determined it is necessary to ensure that physicians and other eligible professionals who order, refer or furnish certain items or services have an approved enrollment record in the Provider Enrollment, Chain and Ownership System (“PECOS”). Items and services that require an order or referral include home health, laboratory, imaging, DMEPOS, and specialist services. It is critical to understand the effect of this initiative, especially the implications for suppliers that simply render services in response to an order or referral from a physician or non-physician practitioner who fails to comply.

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