CMS ‘locks door to vault’

New 'affiliations' authority allows CMS to identify individuals and organizations that pose an undue risk of fraud, waste and abuse based on their relationships with other previously sanctioned entities
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Friday, September 6, 2019

WASHINGTON – CMS has issued a final rule that creates several new revocation and denial authorities to bolster the agency’s efforts to stop waste, fraud and abuse in Medicare, Medicaid and CHIP.

The Program Integrity Enhancements to the Provider Enrollment Process, CMS-6058-FC, contains a new “affiliations” authority that allows CMS to identify individuals and organizations that pose an undue risk of fraud, waste and abuse based on their relationships with other previously sanctioned entities. For example, a currently enrolled or newly enrolling organization that has an owner/managing employee who is “affiliated” with another previously revoked organization can be denied enrollment, or if already enrolled, can have its enrollment because of the problematic affiliation.

“For too many years, we have played an expensive and inefficient game of ‘whack-a-mole’ with criminals—going after them one at a time—as they steal from our programs,” said CMS Administrator Seema Verma. “These criminals engage in the same behaviors again and again. Now for the first time, we have tools to stop criminals before they can steal from taxpayers. This is CMS hardening the target for criminals and locking the door to the vault.”

The rule also includes other authorities that will improve CMS’s fraud-fighting capabilities by providing a basis for administrative action to revoke or deny Medicare enrollment if:

  • A provider circumvents program rules by coming back into the program, or attempting to come back in, under a different name (e.g. the provider attempts to “reinvent” itself);
  • A provider bills for services/items from non-compliant locations;
  • A provider exhibits a pattern or practice of abusive ordering or certifying of Medicare Part A or Part B items, services or drugs; or
  • A has an outstanding debt to CMS from an overpayment that was referred to the Treasury Department.


Additionally, the rule gives CMS the ability to prevent applicants from enrolling in the program for up to three years if a provider is found to have submitted false or misleading information on its initial enrollment application.

Furthermore, the rule expands the reenrollment bar that prevents fraudulent or otherwise problematic providers from re-entering the Medicare program. CMS can now block providers who are revoked from re-entering the program for up to 10 years instead of three years, and for providers revoked a second time, up to 20 years.

The rule goes into effect Nov. 4.