NEW MEDICARE PROVIDER ENROLLMENT CHANGES-2024
Recently, the Centers for Medicare & Medicaid Services (CMS) unveiled updates to the calendar year (CY) 2024 physician fee schedule (PFS) final rule, finalizing specific modifications to Medicare provider enrollment prerequisites. The outlined changes will become effective on January 1, 2024.
The final rule extends CMS’s existing revocation and denial capabilities in two notable manners. Firstly, CMS can now rescind enrollment if a provider, supplier, or any associated individual has incurred a misdemeanor conviction under federal or state law within the previous decade. This action is determined by CMS as having an adverse impact on the best interests of the Medicare program and its beneficiaries. Previously, CMS was solely authorized to revoke Medicare enrollment in cases of specific felonies. CMS indicated that this could encompass any misdemeanor that, in its estimation, jeopardizes the Medicare program or its beneficiaries, such as a malpractice lawsuit leading to a conviction for criminal neglect or misconduct.
Secondly, the final rule broadens CMS’s jurisdiction to revoke and deny enrollment if a provider, supplier, or associated individual has faced a civil judgment under the False Claims Act (FCA) within the previous ten years. Before the CY 2024 final rule, CMS lacked the authority to revoke a provider’s Medicare enrollment solely due to FCA activity. For the purpose of this ground for revocation or denial, “civil judgment” excludes FCA settlement agreements – the provision necessitates a judgment against the provider or supplier.
Moreover, the final rule introduces four new scenarios for retroactive revocation:
Revocations based on misdemeanor convictions: effective date aligns with the date of the misdemeanor conviction. Revocations based on surrendering a state license instead of further disciplinary action: effective date aligns with the date of the license surrender. Revocations based on terminations from a federal healthcare program other than Medicare (e.g., Medicaid): effective date aligns with the date of the termination. Revocations based on specific terminations of a provider agreement: effective date corresponds to, as applicable to the provider type involved, the later of: (i) the provider agreement termination date; or (ii) situations where providers receive payment post-provider agreement termination, the date established by CMS.
Additionally, CMS has concluded an intermediary measure between deactivation and non-action by instituting a “stay of enrollment” for non-compliance with Medicare enrollment prerequisites, subject to CMS discretion. To activate a stay of enrollment, the provider or supplier must demonstrate non-compliance with at least one enrollment requirement remediable through submission of an appropriate enrollment form according to CMS. During the stay duration, the provider remains enrolled, but enrollment is effectively “paused,” resulting in claim rejections. The enrollment stay spans a maximum of 60 days, with the provider granted 15 days to present a rebuttal. If the provider achieves compliance during the stay, retroactive payment will be issued for rejected claims.
In light of CMS’s expanding authority in revoking and denying Medicare enrollment, along with the introduction of temporary enrollment pauses, providers must remain vigilant regarding these imminent changes. Allocation of requisite resources to ensure compliance with Medicare requirements is imperative.