While these new guidelines suggest that Medicare 855 applications may not need to be updated for another year, they do not appear to impact CMS’s ability to apply these rules in situations where a Medicare provider or provider has not yet reported or is not currently required to report CMS affiliation, as discussed in 42 CFR § 424.519 (i).
However, the March 24, 2021 article on MLN Matters contains some interesting claims regarding the Medicare Provider Affiliate Rule. More specifically, it states the following:
We believe that these affiliate disclosure provisions will allow us to better track current and past relationships between and among different providers and suppliers. In addition, they will help us find and take action regarding affiliations between providers and providers posing undue risk to Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP).
Based on the authority of section 1866 (j) (5) of the Social Security Act (the Act), we initially proposed to require affiliate disclosures from all providers and providers on all Medicare initial enrollment and revalidation requests. However, based on comments from commentators, we have decided to take a “step-by-step” approach to the affiliate disclosure provisions.
We will issue affiliate disclosure requests on a discretionary basis. We have the authority to request that a supplier or supplier disclose all applicable affiliations if we learn that the supplier or supplier likely has at least one potentially problematic affiliation. In addition, we may learn about an affiliation through internal data or other means. In practice, we will not request Affiliate Disclosure until we have reviewed the CMS-855 form applications with Affiliate Disclosure Sections. This includes online registration requests in the Supplier Ownership and Registration Chain System (PECOS).
Medicare will review each affiliation on a case-by-case basis, examining the excessive risk factors described in 42 CFR 424.519 (f). We do not focus on technical details based on remote associations with past administrative actions. The affiliate provisions of the final rule also apply to Medicaid and CHIP providers. State Medicaid Agencies (SMAs) will provide additional guidance to their Medicaid and CHIP providers before implementing Medicaid and CHIP membership arrangements.
Given the punitive character of some aspects of the healthcare provider membership rule, it is certainly welcome to see CMS guidelines that the agency will not focus on technical aspects based on remote associations with administrative actions past and reassuring to know that CMS “in practice” may not seek affiliation until it has reviewed health insurance claims 855. However, it remains to be seen whether CMS will continue to issue guidelines. sub-regulatory agencies who perhaps recognize some of the burdens and impact of Medicare’s provider affiliate rule as it attempts to “stop fraud before it happens by keeping providers and problematic providers left out of our federal medicare programs. “