On November 4, CMS' Program Integrity Enhancements to the Provider Enrollment Process final rule goes into effect.
The "Affiliates" provision of this rule requires Medicare, Medicaid and CHIP providers to disclose to CMS any affiliations with organizations that have had a "disclosable event." Providers who fail to make these disclosures can be denied enrollment - or have their enrollment revoked. The purpose of this new process is to stop fraud and help CMS find parties that have committed fraud.
What's an "affiliation"?
There are five ways a provider can have an "affiliation' with an organization:
- a 5% or more direct or indirect ownership interest in another organization
- a general or limited partnership interest (of any percentage) in another organization
- an interest in which an individual or entity exercises "operational or managerial control over, or directly or indirectly conducts, the day-to-day operations of another organization," by contract of another arrangement. This includes sole proprietorships.
- when an individual is acting as officer or director of a corporation
- a reassignment or payment assignment relationship
What's a "disclosable event"?
Providers must disclose "affiliations" within the past five years to CMS if the affiliated organization has a "disclosable event:"
- current uncollected debt owed to Medicare, Medicaid or CHIP
- current or prior payment suspension
- current or prior OIG exclusions
- Medicare, Medicaid or CHIP enrollment denial, revocation or termination