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CMS cracks down: Florida and Illinois counties under home health moratorium

Today, on the home health software blog, we take a look at some important actions taken by CMS that directly impact the industry. CMS recently enacted the first ACA moratorium on new home health agencies in targeted counties in Illinois and Florida. Aimed at fighting fraud and protecting taxpayer monies, industry organizations, such as the VNAA and HCAF applaud this action. Attorney and home care legal expert Elizabeth C. Hogue gives an overview of the rule, how CMS determined the scope of the moratorium and makes an important prediction about the future.

CMS Imposes Moratoriums on New HHA’s

The Centers for Medicare and Medicaid Services (CMS) announced that it will impose moratoriums on enrollment of new home health agencies in the Medicare, Medicaid, and CHIP Programs on July 30, 2012, in certain counties in the Miami and Chicago areas. The counties include Broward and Monroe in the Miami area and Cook, DuPage, Kane, Lake, McHenry, and Will in the Chicago area. Private duty agencies that are not Medicare-certified should take note of the fact that the moratoriums also apply to enrollment of new Medicaid providers.

Under the Affordable Care Act (ACA), Congress provided the Secretary of the Department of Health and Human Services with new tools, including temporary moratoriums on enrollment of new fee-for-services Medicare, Medicaid, and CHIP providers and suppliers, if the Secretary decides that moratoriums are necessary in order to prevent or combat fraud, abuse, and waste. There is no judicial review of decisions to impose temporary enrollment moratoriums, but providers may use the existing appeal procedures to administratively appeal a denial of billing privileges. The scope of such appeals will be limited solely to assessing whether the temporary moratoriums apply to providers.

Before imposing moratoriums, CMS considered both qualitative and quantitative factors related to the risk of fraud, waste, or abuse. CMS consulted with the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services and the Department of Justice. CMS also based its decision in part on the federal government’s experience with the Health Care Fraud Prevention and Enforcement Action Team (HEAT). All of the areas where moratoriums are imposed are cities where the HEAT Medicare Fraud Strike Force teams are active.

CMS also conducted analysis of relevant Medicare and Medicaid enrollment and claims data. Specifically, CMS analyzed factors in all counties across the country with two hundred thousand or more Medicare beneficiaries, including the number of providers per ten thousand Medicare fee-for-service beneficiaries, the compounded annual growth rate in provider enrollments, and the “churn rate,” i.e. the rate at which providers enter and exit the Program as measured by the percent of the target provider community continuously receiving Medicare payments since 2008. The three areas where moratoriums are imposed consistently ranked near the top of these metrics. CMS also determined that beneficiary access to care would not be affected by the moratoriums.

It is also important to note that the temporary moratoriums do not apply to:

  • Changes in practice locations;
  • Changes to provider information (such as telephone numbers, addresses, etc.); or
  • Changes in ownership, except those that require initial enrollment.

Likewise, the moratoriums do not apply to enrollment applications that a CMS contractor has already approved, but which have not yet been entered into the Provider Enrollment Chain and Ownership System (PECOS).

The moratoriums will remain in effect for six months and may be extended for additional six-month periods. After moratoriums are lifted, providers that were unable to enroll because of the moratoriums will be designated to CMS’ highest screen level for new providers for six months from the date moratoriums are lifted.

Providers can expect imposition of additional moratoriums in the future as CMS becomes more adamant about the need to control and prevent fraud and abuse.

©2013 Elizabeth E. Hogue, Esq. All rights reserved

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