CMS Issues Final Rule Targeting Medicare Fraud, Abuse

On Wednesday, CMS issued a final rule that will allow the agency to deny providers the ability to bill Medicare if they have a pattern of inappropriate billing, The Hill reports (Viebeck, The Hill, 12/3).

The final rule will also allow CMS to revoke or deny participation in Medicare from:

• Providers and suppliers of entities with unpaid Medicare debt to prevent individuals or businesses from leaving the program and then re-enrolling in Medicare to avoid paying their debts;
• Providers and suppliers that have an employee in a management position who has been found guilty of a felony that CMS decides is harmful to beneficiaries; and
• Providers that regularly request reimbursements for services that do not meet the program's requirements.

In addition, the rule will standardize Medicare billing privileges across different types of providers, which is projected to save $327 million per year. For example, ambulance services will no longer be able to bill the program for up to 12 months prior to enrolling in Medicare. Further, providers and suppliers will be required to submit all remaining claims within 60 days of having their privileges revoked (Dickson, Modern Healthcare, 12/3).

The rule will take effect after 60 days (CMS rule, 12/3).

Reaction

The American Academy of Family Physicians and the American Medical Association expressed concern that the rule did not clearly define what constitutes a pattern of abusive practice. Both groups noted that Medicare's complex billing requirements make it likely that there will be some amount of physician error.

AAFP President-Elect Wanda Filer said that her group "want[s] to make sure everyone is not overly adjudicated without some due process" (Modern Healthcare, 12/3).