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Changes to the requirements for Medicare provider enrollment could have major consequences for home health providers down the line.
Under provider enrollment requirements, the U.S. Centers for Medicare & Medicaid Services (CMS) has the authority to rescind providers’ Medicare enrollment if they are associated with “bad actors” and are at risk for fraud due to these relationships.
In order to enforce this, CMS will send out requests for affiliation disclosures when made aware that a provider has at least one affiliation that strikes the agency as problematic.
The move is a proactive measure on CMS’s part, private-practice attorney Elizabeth E. Hogue told Home Health Care News.
“What CMS is getting at here is they want to stop fraud before it occurs, as opposed to chasing it after it has already occurred,” she said. “That’s the thrust of these new requirements.”
For now, providers still have some room to breathe. CMS doesn’t plan to request disclosures until Form CMS-855 applications have been updated. This is a process that will potentially be delayed for at least another 12 months, according to Hogue.
Eventually, providers will be asked to disclose current or past affiliations. Some of the relationships CMS considers “affiliations” include having a 5% or more — direct or indirect — ownership interest in another organization. General or limited partnership interest could also be considered an affiliation, as could any interest where an individual or entity effectively wields operational or managerial control over another organization.
Additionally, CMS requires that providers disclose affiliations where an individual is acting as an officer or director of a corporation, as well as any reassignment relationship.
These affiliations are a potential problem when linked to a “disclosable event.” These events include a current uncollected debt, a payment suspension under a federal health care program and exclusion from either the Medicare and or Medicaid programs.
One thing that remains unclear is exactly how CMS plans to apply or enforce these requirements.
“Is CMS, for example, going to refuse to enroll or re-enroll a provider every time they disclose a past affiliation?” Hogue said. “If that is the case, then the consequences are going to be terrible for the home health and health care industry as a whole.”
Hogue noted that this course of action would be a potential worst-case scenario.
“What I hope CMS will do is have providers disclose, but evaluate those disclosures in terms of the risk of fraud and abuse,” she said.
Ultimately, however CMS decides to enforce provider enrollment requirements could mean the difference between providers staying in business or being driven out.
“I think some are going to be driven out of business, and some owners and managers are no longer going to be able to own or be employed in the home health industry, if these requirements are stringently applied,” Hogue said.
For providers hoping to gain some insight into what provider enrollment oversight may look like in the future, CMS has already offered some clues.
“Now, CMS did give us a little hint, unfortunately, when they first published these requirements back in November of 2019,” Hogue said. “In that material was included an estimate of the number of providers who would go out of business as a result of these requirements. That leads me to believe that the enforcement or the application of them may be quite stringent. I hope that that is not the case.”
Moving forward, it will be important for providers to get a jump start on identifying any disclosures that they will be required to make, according to Hogue.
“That means, among their owners, as well as key managers, they’re going to have to say, ‘Have you had any of this in your past? If you have, we want to know the details,’” she said. “As these requirements unfold, as we get more flesh on the bone, [they should be] monitoring what CMS is saying, in light of the affiliations owners and managers will likely have to disclose.”