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 .
Please contact Dominick J. Parris in the Economics and Health Policy Department.