Kusserow on Compliance: Enrollment moratoria for new ambulance suppliers and home health agencies in several states

Over the last two years, I have been reporting on a large number of enforcement actions by the Department of Justice (DOJ) led Medicare Strike Force in eight target cities relating to cases involved home health agencies and ambulance services that many consider to be among the most vulnerable to fraud in health care. The OIG has issued a number of reports related to this problem. Going back to July 2013, CMS made their initial use of authority under the Patient Protection and Affordable Care Act (P.L. 111-148) to use temporary enrollment moratoria to prevent fraud where they have found that certain trends warranted such a moratorium on home health providers and ambulance suppliers in these geographic areas. Once again, they have issued a notice extending the temporary moratoria on the enrollment of new ambulance suppliers and home health agencies (HHAs) in specific locations within metropolitan areas in Florida, Illinois, Michigan, Texas, Pennsylvania, and New Jersey. CMS also placed temporary moratoria on the enrollment of ground ambulance suppliers in Harris County, Texas and other surrounding counties and in Philadelphia, Pennsylvania and surrounding counties. CMS had previously extended all of the above-mentioned moratoria through February 2, 2015. The programs affected by the CMS decision is especially vulnerable to fraud are those that allow the Medicaid recipient to control the selection and payment of personal care attendants.

In determining to extend the moratoria again, CMS considered factors suggesting a high risk of fraud, waste, or abuse by relying on law enforcement’s experience with fraud trends and activities through investigations and prosecutions. CMS then confirmed a high risk of fraud, waste, or abuse in these provider and supplier types through data analysis. The resulting extended moratoria lasts for a period of six months.