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New Medicare Enrollment Guidelines Affecting Existing and Former Enrollees

| Mar 6, 2015 | Medicare Overpayment |

Effective February 3, 2015, new Medicare rules go into effect regarding the enrollment and revocation of licenses of providers and owners. Most significantly, new enrollment rules change how Medicare will consider past unpaid overpayments in reviewing applications for new provider enrollment.

The previous Medicare rules regarding enrollment stated that an owner or provider could not have an existing unpaid overpayment at the time of filing an enrollment application for a new provider.

The new Medicare rules provide that, in addition to considering existing unpaid debt, Medicare may deny enrollment to a provider if the owner was also the owner of a prior provider with Medicare debt within one year, before or after, such prior provider’s termination of enrollment.

The new rules greatly expand Medicare’s ability to deny enrollment to a provider based on the involvement of an owner with a prior provider, even if such owner has not been involved with the prior provider for some time. To avoid a denial, the owner or provider may be required to arrange for payment in full of the prior overpayment debt.

The full text of the new rule regarding Medicare debt is as follows:

(6) Medicare debt.

  1. The enrolling provider, supplier, or owner thereof (as defined in §424.502), has an existing Medicare debt.
  2. The enrolling provider, supplier, or owner (as defined in §424.502) thereof was previously the owner (as defined in §424.502) of a provider or supplier that had a Medicare debt that existed when the latter’s enrollment was voluntarily terminated, involuntarily terminated, or revoked, and all of the following criteria are met:
    1. The owner left the provider or supplier with the Medicare debt within 1 year before or after that provider or supplier’s voluntary termination, involuntary termination or revocation.
    2. The Medicare debt has not been fully repaid.
    3. CMS determines that the uncollected debt poses an undue risk of fraud, waste, or abuse. In making this determination, CMS considers the following factors:
      1. The amount of the Medicare debt.
      2. The length and timeframe that the enrolling provider, supplier, or owner thereof was an owner of the prior entity.
      3. The percentage of the enrolling provider, supplier, or owner’s ownership of the prior entity.
      4. Whether the Medicare debt is currently being appealed.
      5. Whether the enrolling provider, supplier, or owner thereof was an owner of the prior entity at the time the Medicare debt was incurred.
  3. A denial of Medicare enrollment under this paragraph (a)(6) can be avoided if the enrolling provider, supplier or owner thereof does either of the following:
      1. Satisfies the criteria set forth in §401.607; and
      2. Agrees to a CMS-approved extended repayment schedule for the entire outstanding Medicare debt.
    1. Repays the debt in full.
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