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New Rule in Effect for Provider Enrollment Process

In February, the Centers for Medicare & Medicaid Services published its Final rule implementing changes in the provider enrollment processes. Effective March 25, 2011, providers participating in Medicare, Medicaid and Children’s Health Insurance Program will undergo an initial screening process prior to enrollment. In addition, providers are now required to revalidate their compliance with CMS enrollment requirements every five years. Suppliers of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) must revalidate every three years. As a catch all, CMS may demand that any provider revalidate and undergo screening at any time.

The new rule, found in Medicare Program Integrity Manual Chapter 15, sections 19 though 19.4, finalized provisions related to the (1) establishment of provider enrollment screening categories, (2) submission of application fees as part of the provider enrollment process, (3) suspensions of payment based on credible allegations of fraud, and (4) authority to impose a temporary moratorium on the enrollment of new Medicare providers and suppliers of a particular type (or the establishment of new practice locations of a particular type) in a geographic area.

The screening process establishes 3 levels of risk – limited, moderate, or high – and each provider will be assigned to a risk category. The rule also addresses application fees. Providers initially enrolling in Medicare will pay an initial application fee, and current provides will pay the fee when they revalidate.

Providers participating in Medicaid will only pay an application fee to the state agency. Similarly, Medicare providers will pay the fee only for Medicare participation, and state agencies must rely on Medicare’s determination of compliance.

The new rule highlights CMS’ intention to increasingly screen providers and use the enrollment process to combat future fraud. Providers should be aware of the intensified enrollment process and its goal of keeping potential violators out of the Medicare, Medicaid, and Children’s Health Insurance Programs. Further, current participants must maintain a higher level of compliance in order to revalidate their compliance with enrollment requirements every five years.

For more information regarding the Medicare/Medicaid provider enrolment process and compliance programs, please visit or contact a Wachler & Associates attorney at 248-544-0888.

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