The Domino Effect: Tougher Medicare Regulations Have Far Reaching Implications for Florida Physicians

By: Elizabeth P. Perez

Recent changes in federal regulations may expose Medicare and Medicaid providers, particularly physicians, to tougher sanctions. Last year, the Centers for Medicare & Medicaid Services (“CMS”) published a rule that expands its authority to revoke a provider’s Medicare enrollment (“Rule”). The new regulations created by the Rule became effective on February 3, 2015, and were enacted as yet another enforcement tool in the fight against health care fraud and abuse. Undoubtedly, it will have far reaching implications to Florida’s licensed health care providers, particularly physicians.

Now, CMS will have broader discretion to revoke a provider’s Medicare billing privileges for what it deems as the provider’s “pattern or practice” of submitting claims. In a newly added section titled, “Abuse of Billing Privileges,” CMS provides several factors that it will consider to make that determination. For example, it will consider factors such as the percentage of submitted claims that were denied; the reasons for the claim denials, and the length of time over which the pattern has continued.

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