New Update to the Medicare Program Integrity Manual Issued by CMS
Monday, September 24, 2018
By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law
On June 1, 2018, the Centers for Medicare & Medicaid Services (CMS) issued further guidance for reporting and reviewing final adverse legal actions (ALAs) in provider enrollment applications. Section 15.5.3 of the Medicare Program Integrity Manual (MPIM) was updated through Transmittal 797 to provide more guidance on the types of final adverse actions that must be disclosed. It also provides additional instruction to Medicare Administrative Contractors (MACs) on how to process disclosed final adverse actions. New Language Basics. The update in Section 15.5.3 of the MPIM clarifies the scope of disclosure, the time frames for disclosure and the evidence needed to support a disclosure. Per the 2018 update, the list of reportable adverse actions includes: felony and misdemeanor convictions within the last 10 years; current or past suspensions/revocations of a medical license or an accreditation; current or past suspensions or exclusions imposed by the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG); current or past debarments for participation in any Federal Executive Branch procurement or non-procurement program; Medicaid exclusions, revocations, or terminations; and current or past federal sanctions of any type.New Guidance for MACs.
The second part of the update to the Manual provides additional guidance concerning how MACs will review applications and process the disclosure of final adverse actions. The update also covers how MACs should handle both reported and unreported adverse actions. MACs are now required to use either the Provider Enrollment, Chain and Ownership System (PECOS) or the System for Award Management (SAM) to research whether individuals with ownership interest of the applicant entity are excluded. To view all the language in Transmittal 797, which outlines the updated Section 15.5.3, click here. For more information, visit CMS’ website. Click here to view another recent update issued by CMS.
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Sources:King & Spalding. “CMS Updates Rules for Reporting Adverse Legal Action.” JD Supra. (August 25, 2018). Web.Dhillion, Megan. “Update to the Medicare Program Integrity Manual: New Requirements Related to Disclosing and Processing Final Adverse Actions.” AHLA. (August 24, 2018). Web.
About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.KeyWords: Centers for Medicare & Medicaid Services (CMS) representation, CMS defense attorney, representation for medicare issues, representation for Medicaid issues, Medicare defense lawyer, Medicaid defense lawyer, Medicare audit defense attorney, Medicaid audit defense attorney, CMS investigation representation, CMS defense representation, health care fraud representation, healthcare professional representation, representation for physicians, representation for physician reimbursement, professional license defense attorney, medical license defense attorney, professional license representation, licensure defense representation, representation for health care professionals, The Health Law Firm reviews, reviews of The Health Law Firm attorneys, Florida health law defense lawyer, AHCA audit defense lawyer, ZPIC audit defense attorney, RAC audit defense lawyer, Trust Solutions audit defense attorney, First Coast Service Options audit defense attorney, SafeGuard Services audit defense lawyer, Cahaba Safeguard Administrators audit defense lawyer, Noridian NCI audit defense attorney, Health Integrity audit defense lawyer.“The Health Law Firm” is a registered fictitious business name of and a registered service mark of The Health Law Firm, P.A., a Florida professional service corporation, since 1999.Copyright © 2018 The Health Law Firm. All rights reserved.
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