CMS wants to identify bad actors -– even if they are or have been affiliated with a legitimate provider.
On Sept. 5, the Centers for Medicare & Medicaid Services (CMS) issued a new final rule. There was not really a proposed rule to which comments and suggestions could be made; there were Federal Register entries on April 21, 2006, and Feb. 2, 2011.
The comment period and implementation date for the new final rule are both set at Nov. 4, 2019. This is a bit unusual even for CMS, in that we have new rules and regulations within §424 for the Code of Federal Regulations (CFR) to which we must adhere. Broadly, this is the Conditions for Payment section of the CFR, and among other things, this is the location for guidance for the various CMS-855 forms, along with enrollment in the Medicare and associated Medicaid and CHIP (Children’s Health Insurance Program) programs.
While these changes, mainly additions, to the CFR are aimed at reducing fraud and abuse, almost all healthcare providers involved with Medicare will be affected. What CMS is going after is information on affiliated entities and individuals. CMS wants to identify the bad actors – even if they are or have been affiliated with a legitimate provider. Everyone that is involved in Medicare enrollment and the revalidation process should be considering the following:
The basic answer to the fourth question is to stand by. Even though these changes take place as of Nov. 4, 2019, most of the action steps that must be taken will be with CMS, and probably will come through various forms of sub-regulatory guidance.
First let us start with §424.502, Definitions. The following are new.
For those who have worked with the various CM-855 forms, all of these are no doubt quite familiar, with the exception of the reassignment relationship. Apparently, someone like a practitioner who is reassigning Medicare payments may be of interest, relative to affiliations. The question then becomes, who is responsible for reporting such affiliations (that is, the practitioner or the organization to which the practitioner is reassigning Medicare benefits)?
Just from the definitions, it is fairly clear that CMS is serious about reporting anything that is even potentially bad.
“Upon a CMS request, an initially enrolling or revalidating provider or supplier must disclose any and all affiliations that it or any of its owning or managing employees or organizations (consistent with the terms “owner” and “managing employee,” as defined in § 424.502) has or, within the previous five years, had with a currently or formerly enrolled Medicare, Medicaid, or CHIP provider or supplier that has a disclosable event (as defined in § 424.502). CMS will request such disclosures when it has determined that the initially enrolling or revalidating provider or supplier may have at least one such affiliation.”
Note that this statement starts out with, “upon a CMS request…” The last statement in the section indicates that CMS will request such disclosures when there is or may have been an affiliation with an entity or individual during the past five years, relating to a disclosable event. How is CMS even going to know that there was some sort of affiliation? How will this request be made?
The information that must be provided is in §424.519(c):
“The provider or supplier must disclose the following information about each reported affiliation:
Nothing appears out of order in this informational request. Some question might be raised concerning the reason for disclosing, but this would appear to go to the type of problem (debt, suspension, exclusion, etc.) of the affiliated party.
The mechanism for reporting is found at §424.519(e):
“The information required to be disclosed under paragraphs (b) and (c) of this section must be furnished to CMS or its contractors via the Form CMS-855 application (paper or the Internet-based PECOS (Provider Enrollment, Chain, and Ownership System) enrollment process).”
Now this is interesting! Apparently, all of the CMS-855 forms will need updating, and/or some sort of supplemental form will need developing. The CMS-855-R will probably not need changing or any addition, because the affiliation information would be filed with the CMS-855-I for an individual practitioner. The CMS-855-O for ordering and referring practitioners will probably need the additional information, presuming that CMS is interested in any affiliations that an ordering or referring practitioner has or might have had.
CMS is concerned about undue risk with any affiliations. The main concerns have arisen over the duration of the affiliation, whether the affiliation continues, the degree and extent of the affiliation, and disclosable events. This is fully delineated in §424.519(f). Obviously, if CMS determines that there is undue risk of fraud, waste, or abuse, then revocation of enrollment will occur.
CMS does address duplicate data at §414.519(h):
“A provider or supplier is not required to report affiliation data in that portion of the Form CMS-855 application that collects affiliation information if the same data is being reported in the ‘owning or managing control’ (or its successor) section of the Form CMS-855 application.”
While there is a need not to perform duplicate reporting, the fact that the CMS-855 forms are the vehicle for gathering this affiliation information is clear.
This is a long Federal Register entry that requires close study. There are 269 pages in the examination format, of which 28 are devoted to changes (mainly additions) to the CFR. All those who are involved in filing and maintaining the CMS-855 forms will need to carefully study these changes. Note that while we are given some opportunity to comment, this is a final Federal Register. Thus, any weaknesses or omissions will need consideration over time. Anticipate significant subregulatory guidance.
Programming Note:
Listen to Duane Abbey report this story live during Monitor Monday, Sept. 16, 10-10:30 a.m. EST.
While the coverage of telehealth is definitely a good thing, it has caused needless confusion. I would like to address a little of that today.
In the Centers for Medicare & Medicaid Services’ (CMS’s) ongoing attempts to conquer fraud, waste, and abuse, it launched the WISeR (Wasteful and Inappropriate Service
Please log in to your account to comment on this article.
Sepsis sequencing continues to challenge even experienced coding and CDI professionals, with evolving guidelines, documentation gaps, and payer scrutiny driving denials and data inconsistencies. In this webcast, Payal Sinha, MBA, RHIA, CCDS, CDIP, CCS, CCS-P, CCDS-O, CRC, CRCR, provides clear guideline-based strategies to accurately code sepsis, severe sepsis, and septic shock, assign POA indicators, clarify the relationship between infection and organ dysfunction, and align documentation across teams. Attendees will gain practical tools to strengthen audit defensibility, improve first-pass accuracy, support appeal success, reduce denials, and ensure accurate quality reporting, empowering organizations to achieve consistent, compliant sepsis coding outcomes.
Expert presenters Kathy Pride, RHIT, CPC, CCS-P, CPMA, and Brandi Russell, RHIA, CCS, COC, CPMA, break down complex fracture care coding rules, walk through correct modifier application (-25, -57, 54, 55), and clarify sequencing for initial and subsequent encounters. Attendees will gain the practical knowledge needed to submit clean claims, ensure compliance, and stay one step ahead of payer audits in 2026.
Accurately determining the principal diagnosis is critical for compliant billing, appropriate reimbursement, and valid quality reporting — yet it remains one of the most subjective and error-prone areas in inpatient coding. In this expert-led session, Cheryl Ericson, RN, MS, CCDS, CDIP, demystifies the complexities of principal diagnosis assignment, bridging the gap between coding rules and clinical reality. Learn how to strengthen your organization’s coding accuracy, reduce denials, and ensure your documentation supports true medical necessity.
Denials continue to delay reimbursement, increase administrative burden, and threaten financial stability across healthcare organizations. This essential webcast tackles the root causes—rising payer scrutiny, fragmented workflows, inconsistent documentation, and underused analytics—and offers proven, data-driven strategies to prevent and overturn denials. Attendees will gain practical tools to strengthen documentation and coding accuracy, engage clinicians effectively, and leverage predictive analytics and AI to identify risks before they impact revenue. Through real-world case examples and actionable guidance, this session empowers coding, CDI, and revenue cycle professionals to shift from reactive appeals to proactive denial prevention and revenue protection.
In this timely session, Stacey Shillito, CDIP, CPMA, CCS, CCS-P, CPEDC, COPC, breaks down the complexities of Medical Decision Making (MDM) documentation so providers can confidently capture the true complexity of their care. Attendees will learn practical, efficient strategies to ensure documentation aligns with current E/M guidelines, supports accurate coding, and reduces audit risk, all without adding to charting time.
Join Ronald Hirsch, MD, FACP, CHCQM for The PEPPER Returns – Risk and Opportunity at Your Fingertips, a practical webcast that demystifies the PEPPER and shows you how to turn complex claims data into actionable insights. Dr. Hirsch will explain how to interpret key measures, identify compliance risks, uncover missed revenue opportunities, and understand new updates in the PEPPER, all to help your organization stay ahead of audits and use this powerful data proactively.
Stay ahead of the 2026-2027 audit surge with “Top 10 Audit Targets for 2026-2027 for Hospitals & Physicians: Protect Your Revenue,” a high-impact webcast led by Michael Calahan, PA, MBA. This concise session gives hospitals and physicians clear insight into the most likely federal audit targets, such as E/M services, split/shared and critical care, observation and admissions, device credits, and Two-Midnight Rule changes, and shows how to tighten documentation, coding, and internal processes to reduce denials, recoupments, and penalties. Attendees walk away with practical best practices to protect revenue, strengthen compliance, and better prepare their teams for inevitable audits.
As AI reshapes healthcare compliance, the risk of biased outputs and opaque decision-making grows. This webcast, led by Frank Cohen, delivers a practical Four-Pillar Governance Framework—Transparency, Accountability, Fairness, and Explainability—to help you govern AI-driven claim auditing with confidence. Learn how to identify and mitigate bias, implement robust human oversight, and document defensible AI review processes that regulators and auditors will accept. Discover concrete remedies, from rotation protocols to uncertainty scoring, and actionable steps to evaluate vendors before contracts are signed. In a regulatory landscape that moves faster than ever, gain the tools to stay compliant, defend your processes, and reduce liability while maintaining operational effectiveness.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 1 with code CYBER25
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
