If You Owe Money to Medicare . . . No New Group Providers Can be Added

    If You Owe Money to Medicare . . .
    No New Group Providers Can be Added 

    By Justin Vaughn, M.Div, CPC
    Vice President of Compliance


    CMS recently updated provisions to the Medicare Program Integrity Manual, permitting Medicare administrative contractors (MACs) to deny a CMS-855 enrollment application if the entity (eg, medical group) associated with the enrolling provider has an existing overpayment of $1,500 or more that has not been fully repaid at the time the application is filed.

    CMS has instructed its MACs to deny such applications (a) even where the entity has executed a Medicare-approved plan of repayment, and (b) regardless of whether or not there is an appeal under way.  The new rule will go into effect on October 1 of this year.
    This effectively prevents groups from hiring new providers where the group is on the hook for $1,500 or more based on an Medicare audit or RAC demand letter or other CMS overpayment notification.  Accordingly, you will want to make sure you are paid up to the extent possible prior to October 1 if you have plans to add on new providers.

    I want to thank healthcare attorney David Vaughn of Baton Rouge, LA for bringing this matter to my attention.

    The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author’s presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.