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Why does the CMS’ now require disclosure of certain affiliations?

As noted in a previous post, CMS changes tactics, targets health care provider affiliates, the Centers for Medicare and Medicaid Services (CMS) has a new tool in its fight against health care fraud. The tool allows the agency to go after those who affiliate with certain “bad actors,” or other professionals previously accused of health care fraud violations.

In order to avoid prosecution, the CMS’ new rule requires health care providers disclose their affiliations with such parties.

Why did the CMS push for this new tool to fight health care fraud?

The tool is the result, at least in part, of an Early Alert Memorandum put together by the Office of the Inspector General of the Department of Health and Human Services in 2008. The memo stated the agency had gathered evidence to support the finding of a revolving door of fraudulent health care claims from certain suppliers of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS).

The agency stated it was unable to prevent continued fraudulent activity unless the DMEPOS owner had a felony conviction, exclusion from Medicare or debarment from these programs. Essentially, the agency claimed it did not have the tools it needed to stop an individual that has ties to health care fraud schemes from starting up another fraudulent enterprise.

What does this mean for DMEPOS owners?

The change will be burdensome. As discussed in our previous post, noted above, the rule provides the CMS the ability to revoke or deny a provider’s enrollment based on the presence of these allegedly questionable affiliations. Although the agency states most reputable providers and suppliers are unlikely to affiliate with such bad actors, providers will still need to put together a system for tracking information about their affiliations and potentially disclosable events. This information will be invaluable in the event of an investigation.