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CMS Rule: Providers Could Lose Medicare Privileges Because of Tainted 'Affiliations'

CMS on Sept. 5 finalized a program-integrity regulation that’s designed to keep, or kick, providers out of Medicare if they pose an “undue risk” of fraud, waste or abuse. The regulation, which implements provisions of the Affordable Care Act (ACA), requires providers to disclose “affiliations” with other providers who have been suspended or excluded from Medicare, Medicaid or the Children’s Health Insurance Program (CHIP); owe the programs money; or had their billing privileges denied or revoked.

According to the final rule (with comment period), which takes effect Nov. 4, providers will have to report affiliations when they enroll and revalidate as soon as CMS updates the 855 enrollment form. Until then, CMS will identify affiliations through databases, including the Provider Enrollment, Chain, and Ownership System (PECOS). There won’t necessarily be guilt by association. “CMS will, in every case, act with caution and prudence when determining whether an undue risk of fraud, waste, or abuse exists,” the regulation stated. If it does, however, the provider’s relationship with Medicare could be in jeopardy because of its affiliations.

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