Compliance Corner – January 2015

Compliance Corner by van Halem GroupWith the implementation of the Affordable Care Act, the government has been given greater authority to enforce compliance and address fraud, waste and abuse. As noted in our last newsletter, the ACA mandates Compliance Programs as a condition of enrollment in Medicare, Medicaid and CHIP.   Even more compliance efforts under the ACA and Medicare enrollment are being empowered by CMS.

On Dec. 3, 2014, CMS issued a Final Rule under the provisions of the Affordable Care Act that will improve CMS’ ability to deny or revoke the enrollment of entities and individuals that pose a program integrity risk to Medicare.   Provisions of this Final Rule include:

  • adding the ability to deny enrollment to providers, suppliers and owners affiliated with an entity that has unpaid Medicare debt;
  • adding the ability to deny enrollment or revoke billing privileges of providers or suppliers if a managing employee has been convicted of certain felony offenses;
  • permit CMS to REVOKE billing privileges of providers and suppliers that have a pattern or practice of billing for services that do not meet Medicare requirements (regularly submit improper claims); and
  • make the effective date of billing privileges consistent across certain provider and supplier types.

It is more important than ever for all providers and suppliers to have an “effective” Compliance Program that encompasses consistent auditing and monitoring of claims. Your Compliance Program will assist in avoiding government audits or investigations, and prevent your Medicare enrollment from being denied or revoked.

FYI: The OIG is successfully identifying and investigating providers and suppliers who are committing fraud, waste and abuse, which CMS will monitor for their new Medicare enrollment enforcement authority. On Dec. 10, 2014, the OIG HHS released its Semiannual Report to Congress – Fiscal 2014 Report to Congress noting that $4.9 BILLION dollars in improper health care payments are expected to be returned to taxpayers this year.