CMS proposes expanded authority to revoke Medicare privileges

How CMS plans to expand provider enrollment revocations

CMS wants to remove more bad actors from Medicare while clawing back improper payments from them.

First, the proposed rule would expand the number of reasons CMS can take action against a provider, including revoking their Medicare enrollment if they are in an area with what CMS believes is an "excessive" number of providers and suppliers. This makes the provider at high risk for fraud, waste and abuse, CMS explained.

CMS would also be able to deny or revoke a provider's Medicare enrollment if they have been convicted of a misdemeanor related to sexual assault or financial misconduct within the past 10 years.

Additionally, the proposed rule would expand the reasons for provider enrollment revocation or denial, including pausing or revoking Medicare enrollment because a provider's owners or managing organizations have a suspended or revoked license in another state or are in trouble with Medicaid or another federal healthcare program.

Home health agencies, hospices and durable medical equipment suppliers would also face denial or revocation if they fail to reenroll in Medicare and complete the required accreditation or survey following a change in majority ownership.

CMS said its expanded authority would allow it to weed out improper activity by people and organizations that own or operate providers.

Further, the proposed rule would allow provider enrollment revocations to take effect retroactively across the board. While some provider and supplier types receive 30 days' notice after a notice of revocation is mailed, the rule would make revocation effective immediately upon the provider's noncompliance, per CMS.

This means CMS would be able to claw back improper payments retroactively, returning more money to Medicare that should not have been paid in the first place.

The Trump administration has been focused on rooting out fraud, waste and abuse within the government's healthcare programs. In May, the administration even issued a six-month moratorium on hospice and home health agency enrollment in Medicare. Earlier in the year, it paused enrollment of durable medical equipment, prosthetics, orthotics and supplies companies.

Medicare policy updates for home health agencies

As part of annual rulemaking, CMS also proposed payment updates for home health agencies, including the ongoing transition from the Home Health PPS to the Patient-Driven Groupings Model.

In the rule, CMS proposed a -3.0% temporary adjustment to the CY 2027 national standardized payment rate to continue recouping overpayments made to home health agencies between CYs 2020-2025.

CMS said the proposed rule includes an updated home health utilization analysis that compares assumed and actual changes in behavior as home health agencies transition to PDGM. The agency has conducted the analysis since the new payment model went into effect in 2020 to determine changes and provide CMS with data for payment adjustments to compensate.

Since then, CMS has made permanent adjustments, including a -1.023% adjustment last year to account for behavior changes associated with PDGM implementation in CYs 2020 through 2022.

CMS said in the new proposed rule that it continues to believe that the behavior changes may not be directly related to the PDGM, but rather from other changes, such as the continued recalibration of case-mix weights, a change to the Outcome and Assessment Information Set and previous reductions to the home health payment rate.

As such, the proposed temporary adjustment would continue to recoup overpayments in a budget-neutral manner.

The proposed rule would also update the fixed dollar loss amount and continue the recalibration of PDGM case-mix weights, including the functional levels and comorbidity adjustment subgroups.

Additionally, CMS floated in the rule a proposal to include community-based palliative care in the Medicare home health benefit as the agency sees these services as "an important step in the care continuum." The agency also plans to expand examples of skilled palliative care through sub-regulatory guidance following the publication of the final rule.

In addition, the proposed rule would cut the submission deadline for the OASIS from 4.5 months to 45 days, which could make quality information available to the public up to three months sooner.

The National Alliance for Care at Home said in a statement following the rule's release that the overall payment update still does not cover the actual costs of delivering high-quality care.

"While the proposed rate update results in increased payments relative to last year -- a reflection of our continued advocacy and a much-needed reprieve for providers under the stress of increasing costs -- the Alliance remains focused on working to stop unwarranted temporary adjustments that are based on a flawed methodology with underlying data integrity issues," said Jennifer Sheets, CEO of the Alliance.

“We will continue to partner with CMS on policies that strengthen the Medicare home health benefit. Ultimately, federal policy must preserve patient access to care at home, which remains the preferred choice of care for millions of families," Sheets stated.

Jacqueline LaPointe is an Executive Editor at Xtelligent Healthcare Media, covering revenue cycle management, healthcare payers, health policy and health IT since 2016.