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New CMS Rules to Enhance Provider Oversight

On December 3, 2014, The Centers for Medicare & Medicaid Services (CMS) announced new rules that strengthen oversight of Medicare providers and protect taxpayer dollars from corrupt and abusive providers. This new rule is estimated to save $327 million annually. These new safeguards are designed to prevent physicians and other providers with unpaid debt from re-entering Medicare and remove providers with patterns or practices of abusive billing.

For years, some providers tried to work the system and dodge rules to get Medicare dollars. CMS said they have removed nearly 25,000 providers from Medicare and the new rules will help them stop bad providers from coming back in as they continue to protect the patients. This final rule makes it much harder for providers that were removed from the program to come back in.

New changes announced allow CMS to:

  • Deny enrollment to providers, suppliers and owners affiliated with any entity that has unpaid Medicare debt; this will prevent people and entities that have incurred substantial Medicare debts from exiting the program and then attempting to re-enroll as a new business to avoid repayment of the outstanding Medicare debt.
  • Deny or revoke the enrollment of a provider or supplier if a managing employee has been convicted of a felony offense that CMS determines to be detrimental to Medicare beneficiaries. The recently implemented background checks will provide CMS with more information about felony convictions for high risk providers or suppliers.
  • Revoke enrollments of providers and suppliers engaging in abuse of billing privileges by demonstrating a pattern or practice of billing for services that do not meet Medicare requirements.

CMS is clamping down on Medicare fraud, waste and abuse. CMS also currently has in place temporary enrollment delays on new ambulance and home health providers in seven fraud hot spots around the country. This is allowing CMS to target its resources in those areas, including use of fingerprint-based criminal background checks. CMS has demonstrated that removing providers from Medicare has a real impact on savings, identified providers and suppliers who were ultimately revoked prevented $81 million from being paid. This new rule will help CMS reinforce oversight of providers and help to prevent fraud, waste and abuse.

Marc Ryan

Marc S. Ryan serves as MedHOK’s Chief Strategy and Compliance Officer. During his career, Marc has served a number of health plans in executive-level regulatory, compliance, business development, and operations roles. He has launched and operated plans with Medicare, Medicaid, Commercial and Exchange lines of business. Marc was the Secretary of Policy and Management and State Budget Director of Connecticut, where he oversaw all aspects of state budgeting and management. In this role, Marc created the state’s Medicaid and SCHIP managed care programs and oversaw its state employee and retiree health plans. He also created the state’s long-term care continuum program. Marc was nominated by then HHS Secretary Tommy Thompson to serve on a panel of state program experts to advise CMS on aspects of Medicare Part D implementation. He also was nominated by Florida’s Medicaid Secretary to serve on the state’s Medicaid Reform advisory panel.

Marc graduated cum laude from the Edmund A. Walsh School of Foreign Service at Georgetown University with a Bachelor of Science in Foreign Service. He received a Master of Public Administration, specializing in local government management and managed healthcare, from the University of New Haven. He was inducted into Sigma Beta Delta, a national honor society for business, management, and administration.

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