Executive Summary on CMS Proposed Rule on PPACA Enrollment Requirements

The Patient Protection and Affordable Care Act (PPACA) contains several important grants of authority to the Secretary of the U.S. Health and Human Services to impose conditions on the initial enrollment—and continued enrollment—of providers and suppliers in the Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) programs. Because providers and suppliers cannot bill retroactively for services furnished during a period for which they were not enrolled in Medicare, and because billing privileges may be revoked for a period of not less than one and not more than three years, it is imperative that providers and suppliers adhere to the rules for obtaining and retaining billing privileges.

On September 23, 2010, the Centers for Medicare & Medicaid Services (CMS) published a proposed rule (75 FR 58204) that would implement some of the PPACA new enrollment authorities, namely enhanced provider screening under Medicare, Medicaid, and CHIP; mandatory enrollment application fees; temporary moratoria on enrollment of Medicare providers and suppliers, and Medicaid and CHIP providers; suspension of Medicare and Medicaid payments pending investigation of credible allegations of fraud; and termination of provider participation in all states’ Medicaid programs following a termination of provider participation in Medicare or one state’s Medicaid program. The proposed rule also solicits comments regarding the core elements of ethics and compliance programs.

The Executive Summary, authored by attorneys from Foley & Lardner LLP entitled, “CMS Proposed New Regulations to Improve Program Integrity,” hopefully will alert providers and suppliers and their counsel of the need to be aware of the proposed provisions so that they can submit comments and prepare for the final rule.

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