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AIS's Health Business Daily
Featured Story, July 26, 2010 CMS Revs Up Its Process of Terminating Providers From Medicare and Medicaid Reprinted from REPORT ON MEDICARE COMPLIANCE, the nation's leading source of news and strategic information on false claims, overpayments, compliance programs, billing errors and other Medicare compliance issues. By Nina Youngstrom, Managing Editor With enrollment at the forefront of program integrity, CMS announced recently that it has set in motion a process to make sure that providers who are terminated from Medicare or any state Medicaid plan are terminated from all state Medicaid plans, as required by the health reform law.
Medicare terminations include revoking billing privileges, says former CMS attorney Judy Waltz. Providers should take heed of the changes in the reform law and CMS’s implementation of them because terminations may occur for relatively trivial reasons, including paperwork snafus, says Waltz, with Foley and Lardner in San Francisco. And while it’s easier to revoke providers’ Medicare billing numbers than exclude them from Medicare, revocation has a similar effect, especially now that it applies to Medicaid.
The CMS bulletin, issued jointly by the Center for Program Integrity and the Center for Medicaid, CHIP and Survey and Certification, informs states how they will be kept apprised of provider terminations from Medicare and other states. Sec. 6401(b)(2) of the health reform law requires CMS to create a process for providing the names and national provider identifiers (NPIs) of terminated providers to every Medicaid and CHIP agency. Then, starting in January 2011, states must terminate providers from their own Medicaid plan if the providers were terminated from Medicare or another state’s Medicaid plan, according to Sec. 6501 of the health reform law.
Though CMS says it will notify states about terminated providers “in an automated manner,” for now it will use e-mail and post the information on a secure website, which will be updated monthly, according to the bulletin. The website is sponsored by the Medicaid Integrity Institute, a training center established by the CMS Medicaid Integrity Group. In fact, the bulletin included a list of all terminated providers (and suppliers) to facilitate further action by the states.
To ensure the termination list is current, CMS will require all Medicare contractors to submit a monthly list of providers and suppliers who have had their billing privileges revoked. Contractors must include the legal name of the organization or person, the NPI, the correspondence or practice location, the reason for revocation, and the date of revocation.
By moving fast to implement this health reform provision, CMS is again showing it considers enrollment a core program-integrity strategy. In fact, outgoing Medicare Program Integrity Director Kim Brandt said recently that there is no more important program-integrity function than enrollment. CMS has been turning up the heat by pressing providers to use its online enrollment method, the Provider Enrollment, Chain, and Ownership System (PECOS). Medicare contractors in July will launch CMS’s revalidation initiative for hospitals that bill Medicare but haven’t updated their enrollment in the past six years. They will be required to enroll again, either by submitting the 855A form or enrolling through PECOS. Hospitals have 60 days to respond to a revalidation request and produce supporting documentation. “Failure to complete revalidation within 60 days will result in revocation of billing privileges,” according to the Oklahoma Hospital Assn. “By submitting an enrollment application on a voluntary basis, hospitals will avoid the time pressures associated with revalidation.”
Risks Threaten Longstanding Providers
A lot of institutions may not perceive the enrollment crackdown as relevant to them, thinking CMS is focused on fly-by-night durable medical equipment suppliers and Medicaid pill mills, but revalidation will ensnare everyone, Waltz says. “If you don’t respond to a revalidation request or you make a mistake on your re-enrollment application or it’s not complete, your billing privileges could be revoked with a resulting loss of Medicare and Medicaid funding for a year [or more],” according to Waltz. She says historically some providers have delegated the completion of enrollment forms to staffers who haven’t put in the time to ensure the submitted forms are perfect, figuring they could always be revised if necessary. But now you risk losing billing privileges that can cut off most of your cash flow.
There has been a rash of provider billing revocations for seemingly minor reasons, say Waltz and others. Waltz cites the example of an ambulatory surgery center that is having its Medicare billing privileges revoked because it didn’t respond to the Medicare contractor’s first letter warning of a pending revocation. The ASC never received the letter even though it has been in the same location for many years. But Medicare contractors apparently are not required to send revocation letters by certified or registered mail, so there is no way for the ASC to prove it never got the letter, Waltz says. If it had received the letter, the ASC could have responded to whatever concerns the Medicare contractor was raising in the first place.
Corrective action plans sometimes are an option before termination. “They are using revocations for pretty much everything,” she says. “It’s a very significant enforcement risk even for longstanding providers and suppliers who have always considered themselves in good standing with Medicare.” Other lawyers recently have reported on the American Health Lawyers Assn. listserve that Medicare contractors have been revoking hospital billing privileges for failing to notify CMS of new or additional practice locations and similar errors.
CMS and the HHS Office of Inspector General (OIG) have termination authorities for different reasons. Terminations also can be requested by providers (e.g., they retire or for whatever reason no longer want to treat Medicare patients).
CMS Has 16 Grounds for Revocation
OIG may terminate providers who:
CMS can terminate providers for many additional reasons, including failure to furnish ownership information and failure to comply with civil rights requirements. Also, there are 16 bases for CMS to revoke provider billing privileges, which result in termination of the provider agreement. Among the reasons for revocation:
There are differences between termination and exclusion. Effectively, providers excluded by the HHS Office of Inspector General can’t work, directly or indirectly, for health care organizations because ensuring their activities do not involve any federal health care program activity is exceedingly difficult. However, if terminated providers don’t bill Medicare directly for their services, they can still work at health care organizations in administrative functions, notes Howard Young, a former top attorney for the HHS OIG. For example, Young says, a nurse practitioner who was terminated (but not excluded) from Medicare could work in a different capacity at a hospital as long as the services are not directly billable.
Exclusion Also Getting Hot and Heavy
Meanwhile, CMS and states also are ramping up their efforts to keep excluded providers out of Medicare and Medicaid. Last year, CMS sent a letter to state Medicaid directors, reminding them of their obligation to tell providers to screen employees for exclusions. And “states are developing their own exclusion lists” so hospitals and other providers can screen employees for Medicaid exclusions in their states, Young says. The New York state Office of Medicaid Inspector General has a searchable online exclusion database. However, names may appear on one exclusion list but not another, which can complicate screening, says Young, who encourages hospitals to check neighboring states’ exclusion databases because it’s common for clinicians to cross state lines for jobs.
It’s unclear from the CMS bulletin whether Medicaid terminations will be subject to the same wiggle room that exists with Medicare exclusions, Young says. “There are rare situations where exclusions of providers from Medicare or Medicaid are waived,” he says. For example, the state may request an exception because the excluded physician is the sole source of essential specialized services in a particular region, Young says. Sec. 6501 of the health reform law refers to these waiver exceptions, but the June CMS bulletin does not. He wonders whether future CMS guidance will permit states to create exceptions to the cross-state termination requirements to consider individual and extenuating circumstances.
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