There are significant changes in the Medicare Provider Enrollment process that will take effect for 2024. Outlined below are key regulatory updates set to take effect on January 1, 2024, that providers and suppliers should be cognizant of due to their significant impact.
Reasons for Revocation and Denials
The Final Rule extends CMS‘s revocation and denial authorities, introducing several changes. CMS can now revoke enrollment if, within the past 10 years, a provider, supplier, owner, managing employee, organization, officer, or director has either been convicted of a misdemeanor under federal or state law deemed detrimental to Medicare’s best interests, or faced a civil judgment under the False Claims Act (FCA).
Misdemeanors
Unlike the previous limitation to certain felonies, CMS, under the Final Rule, can now deny Medicare enrollment or revoke an existing application for providers or suppliers convicted of a misdemeanor within the past 10 years. This includes misdemeanors posing immediate risks to the Medicare program or its beneficiaries, such as convictions related to criminal neglect or misconduct resulting from malpractice suits.
False Claims Liability
Previously lacking the authority, CMS can now deny Medicare enrollment or revoke an existing application if there’s been a civil judgment under the FCA against the provider, supplier, or related individuals within the past 10 years. FCA settlement agreements are excluded; a judgment against the provider or supplier is required.
Retroactive Revocation
The Final Rule introduces four scenarios for retroactive revocation:
- Misdemeanor convictions under proposed ยง 424.535(a)(16): effective date is the conviction date.
- Revocation based on state license surrender: effective date is the license surrender date.
- Revocation based on termination from a federal health care program other than Medicare: effective date is the termination date.
- Revocation based on termination of a provider agreement under 42 CFR part 489: effective date is, as applicable, the date of provider agreement termination or the date CMS establishes under 42 CFR 489.55.
Stay of Enrollment
CMS introduces a “stay of enrollment” as a middle ground between deactivation and non-action. This allows CMS to pause enrollment for non-compliance, giving providers a 60-day period to remedy non-compliance through submission of the necessary enrollment form. Claims will be rejected during this period, but if compliance is achieved, retroactive payment for rejected claims is provided.
Updates to Practice Locations within 30 Days
CMS, under the Final Rule, requires all providers and suppliers to report changes in practice locations within 30 days, aligning with the previous requirement for physicians/nonpractitioners, durable medical equipment suppliers, and independent diagnostic testing facilities.
Other Changes
Recent updates to various 855 forms, including the CMS-855I for physicians, are not part of the Final Rule but are relevant. Notably, the new form combines the CMS-855I and CMS-855R, recognizing new physician specialties, compact licenses, and expanding practice location types to include telehealth.
Moreover, Change Request 13331 dated November 9, 2023, incorporates the Final Rule’s provider enrollment changes into Chapter 10 of the Medicare Program Integrity Manual.
New Provider Types
As previously reported, CMS now allows enrollment by MHC and MFT practitioners who meet specific criteria.
Practical Takeaways
The Final Rule introduces new authorities for revocation or denial of Medicare enrollment. The discretionary “stay of enrollment” could assist providers in returning to compliance and avoiding revocation. Providers are advised to invest resources in updating enrollment profiles to prevent potential issues, reviewing and correcting inaccuracies as needed.
