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Additional Providers May be at Risk for Losing Medicaid Eligibility Under New Rule

Sep 07 2019

Earlier this week, September 5, the federal government finalized a rule, “Program Integrity Enhancements to the Provider Enrollment Process”, whichexpands the power of the Centers of Medicare & Medicaid Services (CMS) to remove providers from Medicaid (and Medicare) eligibility.  The rule is scheduled to take effect November 4, 2019, and allows CMS to revoke Medicaid eligibility from providers based on a previous association with a banned organization.

Under the new final rule, the Centers for Medicare & Medicaid Services (CMS) has the authority to revoke program eligibility if a provider:

  • has a previous affiliation with a banned organization, even if the provider itself has not been directly hit with a federal investigation
  • bills for services or supplies from “non-compliant locations”
  • demonstrates a pattern of improper ordering of services, supplies, or drugs under Medicare Parts A or B
  • possesses outstanding debt related to Medicare or Medicaid overpayments.
  • attempts to return to the program under a different name than previously utilized and revoked.

The new rule also increases the ban from Medicare participation from three to 10 years for “fraudulent or otherwise problematic” providers and imposes three-year bans to providers that misrepresent themselves on their initial Medicare application.   Providers that receive a ban, return, and commit another offense are subject to a twenty year ban.

CMS’ Press Release can be found here: https://www.cms.gov/newsroom/press-releases/cms-announces-new-enforcement-authorities-reduce-criminal-behavior-medicare-medicaid-and-chip

Written by Stotler Hayes · Categorized: Medicaid

Stotler Hayes Group, LLC is a national, boutique law firm focused on optimizing recovery for health care providers through Medicaid, Medicare, private collections, training and education. Our attorneys are licensed in, and represent clients before, federal and state courts and agencies in a majority of states around the country.

In the handful of states where Stotler Hayes Group, LLC does not employ a full-time attorney, referrals are made to local counsel, many of whom we have developed close working relationships with over the years. In those cases, our firm works with local counsel throughout the pendency of the case.

Stotler Hayes Group, LLC,

Principal Office: Pawley’s Island, SC, Phone: 843-235-9871; Fax: 888-497-7390; email: info@stotlerhayes.com

This website is for informational purposes only. Please remember that every case is different. Any result we achieve for one client in one matter does not necessarily indicate similar results can be obtained for other clients.

The attorney responsible for the content of this website is Andrea Kirksey, Esq., Executive Director and General Counsel for Stotler Hayes Group, LLC, 297 Willbrook Boulevard,  Pawley’s Island, South Carolina.

She may be contacted at (843) 235-9871, ext. 1002 or at akirksey@stotlerhayes.com.

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