April 18, 2014

Centers for Medicare & Medicaid Services (CMS) Delays Edits to Deny Claims When Ordering/Referring Provider Not Enrolled in Medicare and Issues Proposed Rule on Enrollment Restrictions

The Centers for Medicare & Medicaid Services temporarily delayed the implementation of edits relating to ordering/referring practitioners that were scheduled to go into effect May 1, 2013, and issued a proposed rule with revisions to its enrollment regulations.

The Centers for Medicare & Medicaid Services (CMS) has temporarily delayed implementation of edits relating to ordering/referring practitioners that were scheduled to go into effect May 1, 2013.  CMS will advise providers and suppliers of the new implementation date in the near future, at which point CMS will deny claims from laboratories, imaging centers, suppliers of durable medical equipment, orthotics, prosthetics and supplies, and Part A Home Health Agencies (HHA) for services or supplies when the ordering/referring practitioner (1) does not have a current Medicare enrollment record with a valid National Provider Identifier or (2) is of a type that is not eligible to order or refer for Medicare beneficiaries.  (View “CMS to Deny Claims When Ordering/Referring Provider Not Enrolled in Medicare” for more information.)

CMS also issued a proposed rule with revisions to its enrollment regulations, which include:

  • Clarifying that suppliers who enroll via the CMS-855O solely to order or certify cannot bill the Medicare program and are not granted Medicare billing privileges

  • Expanding the instances in which a felony conviction can serve as a basis for denial or revocation of a provider or supplier’s enrollment

  • Enabling CMS to deny enrollment if the enrolling provider, supplier or owner thereof had an ownership relationship with a previously enrolled provider or supplier that had a Medicare debt

  • Enabling CMS to revoke Medicare billing privileges if it determines that a provider or supplier has a pattern or practice of submitting claims for services that fail to meet Medicare requirements

  • Requiring revoked providers or suppliers regardless of type to submit, within 60 days after the effective date of the revocation, all claims for items and services furnished prior to the effective date of the revocation letter (for HHAs the date would be 60 days after the later of the effective date of the revocation or the date that the HHA’s last payable episode ends)

  • Specifying that all re-enrollment bars begin 30 days after CMS or the CMS contractor mails notice of the revocation determination to the provider or supplier

  • Permitting providers and suppliers only one opportunity to correct all deficiencies that serve as the basis of revocation through a Corrective Action Plan

  • Limiting the ability of ambulance suppliers to bill for services performed prior to enrollment

CMS believes these measures will improve its ability to detect new fraud schemes and help ensure fraudulent entities and individuals do not enroll in or maintain their enrollment in the Medicare program.  Comments to the proposed rules can be submitted through June 28, 2013.

© 2014 McDermott Will & Emery

About the Author


Joan Polacheck is a partner in the law firm of McDermott Will & Emery LLP and is based in the Firm’s Chicago office. She represents a broad range of health care industry clients, including hospitals, suppliers, and drug and device companies.


About the Author


Monica A. Wallace is an associate in the law firm of McDermott Will & Emery LLP and is based in the Firm’s Chicago office.  She focuses her practice on complex regulatory and transactional counseling to health care organizations such as health systems, hospitals, physician groups, integrated delivery systems, durable medical equipment prosthetics and orthotics suppliers, home health agencies, and other health care providers. Monica’s regulatory practice focuses on the Anti-Kickback and Stark laws; Medicare and Medicaid reimbursement and billing; legal...


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