Effective February 21, 2017 the Centers for Medicare & Medicaid Services (CMS) issued a number of additional conditions under which providers should know about a rule or policy. Currently, CMS requires Medicare Administrative Contractors (MAC) to consider at least one of three conditions when it assumes that a provider or supplier should know about a given policy or rule. The three previous conditions were:
- The policy or rule is in the provider manual or in Federal regulations,
- The CMS Contractor provided general notice to the medical community concerning the policy or rule, or
- The CMS Contractor gave written notice of the policy or rule to the particular provider
The additional considerations that CMS is asking MACs to utilize are as follows:
- The provider, physician, or other supplier was previously investigated or audited as a result of not following the policy or rule;
- The provider, physician, or other supplier previously agreed to a Corporate Integrity Agreement as a result of not following the policy or rule;
- The provider, physician, or other supplier was previously informed that its claims had been reviewed/denied as a result of the claims not meeting certain Medicare requirements which are related to the policy or rule; or
- The provider, physician, or other supplier previously received documented individual training/outreach from CMS or one of its contractors related to the same policy or rule.
Information on provider liability can be found in the Medicare Financial Management Manual.
Please contact Dominick J. Parris in the Economics and Health Policy Department.