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by Elizabeth E. Hogue, Esq.
Provider Enrollment
Gamechangers for all Providers
There is a new Medicare provider enrollment “sheriff” in town and the sheriff has great big, new guns!
Provider enrollment in the Medicare has become a key tool to combat fraud and abuse. Enforcers characterize the emphasis on provider enrollment as a rejection of “pay and chase” i.e. enroll providers and then go after them when they mess up!
New tools CMS likely to use
- CMS now has the power to exclude providers from participation in the Medicare Program. This power was previously exercised by the Office of Inspector General.
- (OIG) of the U.S. Department of Health and Human Services (HHS) only. This key new authority alone changes the landscape of provider enrollment/program integrity in the Medicare Program completely.
- CMS can now make revocations in enrollment in the Medicare Program effective as of the date the noncompliance began. Recoveries of payments will likely be allowed dating back to that point. Think about this one! Recoveries could go all the way back to the establishment of providers however many years ago that was.
- Enrollment in the Medicare Program may also be denied or revoked if enrollment presents a high risk of fraud, waste and abuse because of excessive concentration of providers and suppliers within a limited geographic area. This new authority is intended to be targeted in scope. That is, CMS is supposed to consider the facts and circumstances of each case. At lease anecdotally, it appears that CMS’ recent decisions to disenroll or suspend payments to multiple hospices in California for this reason were not based on consideration of specific facts and circumstances; actions seems to be taken “wholesale.” Hospices that were established years ago subject to long-term office leases, for example, were located in geographic areas in which the number of providers subsequently expanded substantially were nonetheless swept up in enforcement actions.
- CMS will also likely gain the ability to revoke enrollment based on abuse of billing privileges that involves “several claims” only. CMS has been able to revoke billing privileges on this basis only if relied on the percentage of claims denied and providers’ history of adverse action.
Your Attention Please
Historically, providers may have taken a blasé attitude toward the process of provider enrollment and reenrollment. Those days are over! Issues related to provider enrollment now demand attention from top managers and legal counsel in order to maintain enrollment in the Medicare Program.
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Elizabeth Hogue is an attorney in private practice with extensive experience in health care. She represents clients across the U.S., including professional associations, managed care providers, hospitals, long-term care facilities, home health agencies, durable medical equipment companies, and hospices.
©2026 Elizabeth E. Hogue, Esq. All rights reserved.
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