United States: Program Integrity Changes To The Medicare Provider Enrollment Process

On March 1, 2016, the U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services (CMS) published a proposed rule (Proposed Rule) entitled "Medicare, Medicaid, and Children's Health Insurance Programs; Program Integrity Enhancements to the Provider Enrollment Process". The Proposed Rule addresses Medicare, Medicaid and Children's Health Insurance Program (CHIP) enrollment and revalidation reporting requirements, as well as expanded CMS authority intended to increase program integrity through the Medicare enrollment process. CMS is accepting public comments on the Proposed Rule until May 1, 2016.


In response to concerns that certain providers and suppliers were able to evade federal health care program integrity provisions by changing names or establishing complex entity relationships, the Affordable Care Act incorporated additional requirements in Section 1866(j)(5) of the Social Security Act for disclosure of certain information at enrollment and revalidation intended to identify such relationships before enrolling and making payments to entities that would not otherwise be eligible for enrollment. The Proposed Rule seeks to implement the requirements of Section 1866(j)(5), as well as provide CMS with additional authority related to denial or revocation of Medicare enrollment and imposition and extension of Medicare reenrollment bars.

The Proposed Rule

Disclosure of Affiliations and Disclosable Events

Under the Proposed Rule, CMS intends to implement the disclosure requirements under Section 1866(j)(5) that require providers and suppliers seeking Medicare enrollment or revalidation to disclose current or past (within the last five years) affiliations with individuals and entities that have or have had a "disclosable event", including: (1) any current uncollected debt to Medicare, Medicaid, or CHIP (regardless of the amount or status of appeal or repayment terms); (2) any prior or current payment suspension under a federal health program; (3) any exclusion from participation in Medicare, Medicaid, or CHIP (including exclusions under appeal); or (4) any denial, revocation or termination of Medicare, Medicaid or CHIP enrollment (regardless of the reason and including decisions under appeal). CMS proposes to define "affiliation" to include:

  • A 5 percent or greater direct or indirect ownership interest in another organization;
  • A general or limited partnership interest in an entity, regardless of the ownership interest;
  • The exercise of operational or managerial control, or directly or indirectly conducting the day-to-day operations of another organization;
  • Acting as an officer or director of a corporation; and
  • Any reassignment relationship under 42 CFR § 424.80.

The Proposed Rule defines "uncollected debt" to include certain overpayments and civil monetary penalties and assessments. As proposed, enrollment applicants also must disclose if any of their owners or managing employees or organizations has or had an affiliation involving a disclosable event.

Notably, as proposed, applicants must report disclosable affiliations regardless of whether the affiliated provider or supplier was enrolled in a federal health care program during the term of the affiliation and regardless of when the disclosable event occurred. CMS is seeking comments as to whether it should apply a lookback period for disclosable events (as it proposed in the case of a five-year lookback for affiliations), and if so, how long that period should be. A provider or supplier must also report changes to existing affiliations and information regarding new affiliations.

Increased Authority to Revoke or Deny Medicare Enrollment

Under the Proposed Rule, CMS may deny or revoke a provider's or supplier's enrollment if the provider or supplier fails to fully and completely disclose affiliations with disclosable events (as discussed above), or if CMS determines any of the disclosed affiliations poses an undue risk of fraud, waste or abuse. In evaluating the risk of a disclosed affiliation, CMS will consider the following factors:

  • The duration of the affiliation;
  • Whether the affiliation still exists or when it ended;
  • The extent of the affiliation (e.g., percent ownership);
  • The reason the affiliation was terminated;
  • The type of disclosable event;
  • When the disclosable event occurred;
  • Whether the affiliation existed at that time; and
  • Any other evidence CMS deems relevant.

In the case of uncollected debt, CMS will evaluate the amount, steps (if any) toward repayment and to whom the debt is owed. In the case of denials, revocations, terminations, exclusions or payment suspensions, CMS will evaluate the reason for the action.

CMS also proposes to expand its authority to deny and/or revoke a provider's or supplier's Medicare enrollment in the following circumstances:

  1. If CMS determines the provider's or supplier's billing privileges are currently revoked under a different name, numerical identifier, or business identity, CMS may revoke or deny the provider's or supplier's enrollment. In its investigation, CMS would consider the degree of commonality among the owning and managing employees and organizations; geographic location; provider or supplier type; business structure; and any other evidence indicating that the two parties are similar.
  2. If a provider or supplier bills Medicare for services performed at or items furnished from a location it knew or should have known did not comply with the Medicare enrollment requirements, CMS may revoke the provider's or supplier's enrollment (including all of the provider's or supplier's locations, regardless of whether they are part of the same enrollment). As proposed, CMS could revoke multiple provider and supplier locations even if the sites have different numerical identifiers, legal business names or ownership as long as evidence suggests that they are effectively under the control of similar parties.
  3. If CMS determines a physician or eligible professional has a pattern or practice of ordering, certifying, referring, or prescribing Medicare Part A or B services, items or drugs that are abusive, represents a threat to the health and safety of Medicare beneficiaries, or otherwise fails to meet Medicare requirements, CMS may revoke the physician or eligible professional's enrollment. As proposed, CMS will consider the following factors in making its determination, whether: (1) the diagnoses supports the orders, certifications, referrals, or prescriptions at issue; (2) there are instances where items or drugs ordered, certified, referred, or prescribed could not have occurred (e.g., the patient was deceased); (3) any prior disciplinary action has been taken against the individual; (4) there was any prior restriction, suspension, or revocation of an individual's ability to provide health care or participate in an insurance program; (5) the length of time the pattern has continued; (6) the length of time the physician or eligible professional has been enrolled in Medicare; and (7) malpractice suits filed against the professional. CMS will also consider any other information it deems relevant.
  4. If a provider or supplier has an existing debt that CMS refers to the Department of the Treasury, CMS may revoke the provider's or supplier's enrollment.
  5. If an enrolled individual or entity fails to report changes to certain enrollment information (e.g., changes of location or ownership, final adverse actions) within 30 or 90 days, depending on the entity type and information involved, CMS may revoke the provider's or supplier's enrollment. In evaluating the failure to report, CMS proposes to consider the following criteria: (1) whether the information was reported; (2) if reported, how belatedly; (3) the materiality of the information; and (4) any other information CMS deems relevant to its evaluation and determination of the revocation.
  6. If a provider's or supplier's owning or managing employee or organization has been placed under a Medicare or Medicaid payment suspension, CMS may deny the provider's or supplier's Medicare enrollment. This proposal expands CMS' current authority to deny Medicare (not Medicaid) enrollment to provider's or supplier's whose current owner, physician or non-physician practitioners are subject to Medicare payment suspensions. As proposed, CMS could apply its expanded authority to any of the provider's or supplier's owning or managing employees, to the organization's current or former names, numerical identifiers or business identities, and to any of the provider's or supplier's existing enrollments.
  7. If a provider's or supplier's license is currently revoked or suspended in a state other than that in which the provider or supplier is enrolling, or if the provider or supplier is currently terminated or suspended from participation in a state Medicaid program or any other federal health care program, CMS may deny the provider's or supplier's Medicare enrollment application. In addition, CMS proposes to expand its authority to revoke a provider's or supplier's enrollment if the provider or supplier is terminated, revoked or barred from participation in any other federal health care program and the provider or supplier has exhausted all applicable appeal rights.
  8. If CMS determines a provider or supplier voluntarily terminated its Medicare enrollment to avoid a revocation, CMS may revoke the provider's or supplier's enrollment.

Increased Reenrollment Bar

CMS proposes to lengthen three reenrollment bars. First, CMS proposes to increase the maximum reenrollment bar from three years to 10 years, subject to exceptions where greater bars may be warranted. CMS notes that revocations that typically involve a one-year reenrollment bar would not necessarily result in a longer revocation period under the Proposed Rule. CMS indicates that the extended reenrollment bars would be limited to "egregious cases of fraudulent, dishonest or abusive behavior."

Second, CMS proposes to increase a provider's or supplier's imposed reenrollment bar by three years (even if it exceeds the proposed 10-year maximum) if CMS determines that the provider or supplier is attempting to circumvent its existing reenrollment bar based on the criteria under Section 1866(f)(5).

Third, CMS proposes to apply a 20-year reenrollment bar to providers and suppliers whose Medicare enrollment is revoked for a second time.

Reapplication Bar

Under the Proposed Rule, CMS would have the authority to impose a reapplication bar of up to three years where a Medicare enrollment application is denied for submission of false or misleading information or where information is omitted in order to obtain enrollment.

Both the reapplication bar, and the reenrollment bars (above) would be applied to the previously enrolled or applicant entity under any current, former or future name, numerical identifier or business identity.

Expansion of Ordering/Certifying Requirements and Maintenance of Documentation

Under the Proposed Rule, CMS would require that in order to order, certify, refer or prescribe any Part A or B service, item or drug, a physician or eligible professional must be enrolled in Medicare or have validly opted-out of the Medicare program. In addition, CMS proposes that a provider or supplier furnishing a Part A or B service, item or drug, and the physician or eligible professional furnishing, ordering, certifying, referring or prescribing a Part A or B service, item or drug must maintain documentation for seven years from the date of service.

Changes to CMS' Enrollment Moratoria Authority

Under the Proposed Rule, CMS seeks to prohibit providers and suppliers from moving an existing practice location to inside an enrollment moratorium area. In CMS' view, this effectively establishes an additional site in the moratorium area, which is something the moratorium is designed to prevent. In addition, CMS proposes to expand the exception for active enrollment applications excepted from an imposed moratorium. The current rule excepts only enrollment applications that have been approved by a Medicare contractor but not yet entered into PECOS at the time of the moratorium. As proposed, the exception would include applications that have been received by the Medicare contractor prior to the moratorium being imposed.

New Authority to Reject DMEPOS Sureties

CMS proposes to amend the DMEPOS surety bond requirements to enable CMS to reject any and all surety bonds furnished by a surety which has failed to submit a payment to CMS in accordance with a surety bond required by 42 CFR § 424.57(d). As proposed, if CMS rejects a surety bond, the enrolling or enrolled DMEPOS supplier would have to obtain a new bond from a new surety in order to enroll or maintain its Medicare enrollment. CMS notes that it would reserve the right to reject all of a surety's existing bonds (even those for suppliers unrelated to the noncompliant bond) if the surety fails to make even one required payment; however, it would consider the circumstances surrounding the surety and its failure to pay before requiring suppliers to obtain new bonds from a different surety or rejecting bonds issued to DMEPOS suppliers by the non-compliant surety.

Changes to Provider and Supplier Reactivation

Under the Proposed Rule, CMS seeks to modify the process for reactivating a provider's or supplier's Medicare billing privileges by permitting a provider or supplier to recertify its enrollment information currently on file with Medicare and furnish any missing information as appropriate. As proposed, CMS may require a deactivated provider or supplier submit a new enrollment application before reactivating its billing privileges.


The Proposed Rule would impose significant additional burdens on existing and new Medicare providers and suppliers to identify, evaluate and report certain arrangements and relationships for Medicare enrollment purposes. The reporting requirements, coupled with the revocation and reenrollment bar penalties, may have far-reaching implications for providers and suppliers who are otherwise without fault, but may have unknowingly engaged in arrangements with individuals or organizations that CMS has identified as presenting a risk to federal health care program integrity. Providers and suppliers should review the proposed rule carefully and consider providing comments to CMS.

Program Integrity Changes To The Medicare Provider Enrollment Process

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

To print this article, all you need is to be registered on Mondaq.com.

Click to Login as an existing user or Register so you can print this article.

In association with
Related Video
Up-coming Events Search
Font Size:
Mondaq on Twitter
Register for Access and our Free Biweekly Alert for
This service is completely free. Access 250,000 archived articles from 100+ countries and get a personalised email twice a week covering developments (and yes, our lawyers like to think you’ve read our Disclaimer).
Email Address
Company Name
Confirm Password
Mondaq Topics -- Select your Interests
 Law Performance
 Law Practice
 Media & IT
 Real Estate
 Wealth Mgt
Asia Pacific
European Union
Latin America
Middle East
United States
Worldwide Updates
Check to state you have read and
agree to our Terms and Conditions

Terms & Conditions and Privacy Statement

Mondaq.com (the Website) is owned and managed by Mondaq Ltd and as a user you are granted a non-exclusive, revocable license to access the Website under its terms and conditions of use. Your use of the Website constitutes your agreement to the following terms and conditions of use. Mondaq Ltd may terminate your use of the Website if you are in breach of these terms and conditions or if Mondaq Ltd decides to terminate your license of use for whatever reason.

Use of www.mondaq.com

You may use the Website but are required to register as a user if you wish to read the full text of the content and articles available (the Content). You may not modify, publish, transmit, transfer or sell, reproduce, create derivative works from, distribute, perform, link, display, or in any way exploit any of the Content, in whole or in part, except as expressly permitted in these terms & conditions or with the prior written consent of Mondaq Ltd. You may not use electronic or other means to extract details or information about Mondaq.com’s content, users or contributors in order to offer them any services or products which compete directly or indirectly with Mondaq Ltd’s services and products.


Mondaq Ltd and/or its respective suppliers make no representations about the suitability of the information contained in the documents and related graphics published on this server for any purpose. All such documents and related graphics are provided "as is" without warranty of any kind. Mondaq Ltd and/or its respective suppliers hereby disclaim all warranties and conditions with regard to this information, including all implied warranties and conditions of merchantability, fitness for a particular purpose, title and non-infringement. In no event shall Mondaq Ltd and/or its respective suppliers be liable for any special, indirect or consequential damages or any damages whatsoever resulting from loss of use, data or profits, whether in an action of contract, negligence or other tortious action, arising out of or in connection with the use or performance of information available from this server.

The documents and related graphics published on this server could include technical inaccuracies or typographical errors. Changes are periodically added to the information herein. Mondaq Ltd and/or its respective suppliers may make improvements and/or changes in the product(s) and/or the program(s) described herein at any time.


Mondaq Ltd requires you to register and provide information that personally identifies you, including what sort of information you are interested in, for three primary purposes:

  • To allow you to personalize the Mondaq websites you are visiting.
  • To enable features such as password reminder, newsletter alerts, email a colleague, and linking from Mondaq (and its affiliate sites) to your website.
  • To produce demographic feedback for our information providers who provide information free for your use.

Mondaq (and its affiliate sites) do not sell or provide your details to third parties other than information providers. The reason we provide our information providers with this information is so that they can measure the response their articles are receiving and provide you with information about their products and services.

If you do not want us to provide your name and email address you may opt out by clicking here .

If you do not wish to receive any future announcements of products and services offered by Mondaq by clicking here .

Information Collection and Use

We require site users to register with Mondaq (and its affiliate sites) to view the free information on the site. We also collect information from our users at several different points on the websites: this is so that we can customise the sites according to individual usage, provide 'session-aware' functionality, and ensure that content is acquired and developed appropriately. This gives us an overall picture of our user profiles, which in turn shows to our Editorial Contributors the type of person they are reaching by posting articles on Mondaq (and its affiliate sites) – meaning more free content for registered users.

We are only able to provide the material on the Mondaq (and its affiliate sites) site free to site visitors because we can pass on information about the pages that users are viewing and the personal information users provide to us (e.g. email addresses) to reputable contributing firms such as law firms who author those pages. We do not sell or rent information to anyone else other than the authors of those pages, who may change from time to time. Should you wish us not to disclose your details to any of these parties, please tick the box above or tick the box marked "Opt out of Registration Information Disclosure" on the Your Profile page. We and our author organisations may only contact you via email or other means if you allow us to do so. Users can opt out of contact when they register on the site, or send an email to unsubscribe@mondaq.com with “no disclosure” in the subject heading

Mondaq News Alerts

In order to receive Mondaq News Alerts, users have to complete a separate registration form. This is a personalised service where users choose regions and topics of interest and we send it only to those users who have requested it. Users can stop receiving these Alerts by going to the Mondaq News Alerts page and deselecting all interest areas. In the same way users can amend their personal preferences to add or remove subject areas.


A cookie is a small text file written to a user’s hard drive that contains an identifying user number. The cookies do not contain any personal information about users. We use the cookie so users do not have to log in every time they use the service and the cookie will automatically expire if you do not visit the Mondaq website (or its affiliate sites) for 12 months. We also use the cookie to personalise a user's experience of the site (for example to show information specific to a user's region). As the Mondaq sites are fully personalised and cookies are essential to its core technology the site will function unpredictably with browsers that do not support cookies - or where cookies are disabled (in these circumstances we advise you to attempt to locate the information you require elsewhere on the web). However if you are concerned about the presence of a Mondaq cookie on your machine you can also choose to expire the cookie immediately (remove it) by selecting the 'Log Off' menu option as the last thing you do when you use the site.

Some of our business partners may use cookies on our site (for example, advertisers). However, we have no access to or control over these cookies and we are not aware of any at present that do so.

Log Files

We use IP addresses to analyse trends, administer the site, track movement, and gather broad demographic information for aggregate use. IP addresses are not linked to personally identifiable information.


This web site contains links to other sites. Please be aware that Mondaq (or its affiliate sites) are not responsible for the privacy practices of such other sites. We encourage our users to be aware when they leave our site and to read the privacy statements of these third party sites. This privacy statement applies solely to information collected by this Web site.

Surveys & Contests

From time-to-time our site requests information from users via surveys or contests. Participation in these surveys or contests is completely voluntary and the user therefore has a choice whether or not to disclose any information requested. Information requested may include contact information (such as name and delivery address), and demographic information (such as postcode, age level). Contact information will be used to notify the winners and award prizes. Survey information will be used for purposes of monitoring or improving the functionality of the site.


If a user elects to use our referral service for informing a friend about our site, we ask them for the friend’s name and email address. Mondaq stores this information and may contact the friend to invite them to register with Mondaq, but they will not be contacted more than once. The friend may contact Mondaq to request the removal of this information from our database.


This website takes every reasonable precaution to protect our users’ information. When users submit sensitive information via the website, your information is protected using firewalls and other security technology. If you have any questions about the security at our website, you can send an email to webmaster@mondaq.com.

Correcting/Updating Personal Information

If a user’s personally identifiable information changes (such as postcode), or if a user no longer desires our service, we will endeavour to provide a way to correct, update or remove that user’s personal data provided to us. This can usually be done at the “Your Profile” page or by sending an email to EditorialAdvisor@mondaq.com.

Notification of Changes

If we decide to change our Terms & Conditions or Privacy Policy, we will post those changes on our site so our users are always aware of what information we collect, how we use it, and under what circumstances, if any, we disclose it. If at any point we decide to use personally identifiable information in a manner different from that stated at the time it was collected, we will notify users by way of an email. Users will have a choice as to whether or not we use their information in this different manner. We will use information in accordance with the privacy policy under which the information was collected.

How to contact Mondaq

You can contact us with comments or queries at enquiries@mondaq.com.

If for some reason you believe Mondaq Ltd. has not adhered to these principles, please notify us by e-mail at problems@mondaq.com and we will use commercially reasonable efforts to determine and correct the problem promptly.