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CMS announces increased health care fraud enforcement measures

The United States Centers for Medicare and Medicaid Services (CMS) recently announced a new rule to address health care fraud. The announcement was made in September 2019. The new rule expands the agency’s ability to revoke or deny applications for entry or re-enrollment into the Medicare, Medicaid and CHIP payment programs.

On way the rule, titled the Program Integrity Enhancements to the Provider Enrollment Process, achieves this goal is through the use of an "affiliations authority" to identify those most likely to commit fraud, waste or abuse.

How will the government identify those most likely to commit fraud, wastes or abuse under the affiliations authority?

The CMS will review individuals and organizations for any affiliation with previously sanctioned organizations. The presence of such an affiliation could be enough to justify the denial or revocation of enrollment in Medicare, Medicaid and CHIP.

Were there any other changes?

The rule led to additional measures aimed at fighting fraud, including: the ability to deny those who attempt to fraudulently re-enter the system after a revocation or denial by using a different name and those with certain outstanding debts to CMS as well as the ability to prevent enrollment of those who provide false or misleading information on their initial enrollment application.

These are just CMS' most recent measures aimed at searching out and punishing those who commit health care fraud. In addition to punishing potential offenders, the CMS also hopes the rule will deter others from engaging in fraudulent activity. The government’s crackdown on these crimes may increase as a result of this new rule and lead to a surge in government investigations into allegations of health care fraud.

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