CMS Launches Yet Another Reason for Providers To Take Enrollment Seriously
-
On the heels of all the DME enrollment segments, CMS has announced several new, potentially more powerful penalties which may affect all providers, not just DME providers. Simply put, these new penalties may severely impact your ability to practice.
Some of the proposed penalties offered by CMS in the 2027 rule making may affect your ability to practice include:
- Revoke enrollment of DMEPOS providers which do not comply with their 36-month change in majority ownership rule. This rule precludes changes in ownership within 36 months of any previous ownership changes. CMS maintains steady ownership reduces fraud and abuse.
- Even without a finding of fraud, CMS may have the authority to deny or revoke enrollment when CMS determines a provider’s location presents a significant risk of fraud, waste or abuse because there are too many providers in a limited geographic area. They don’t say what that concentration is. More on this in future columns.
- Authority to deny or revoke enrollment based on certain misdemeanor convictions involving sexual assault or financial misconduct within the previous 10 years.
- Authority to revoke your enrollment if you share space with a revoked provider This even with no wrongdoing on your part.
- Authority to revoke your DME enrollment if your Part B Medicare or other CMS program enrollments are revoked. Potentially more economically damaging is if your DME enrollment is revoked, your Part B Medical Medicare billing privileges may be revoked.
- An expanded reenrollment bar of up to ten years, for ANY denial reason.
- Expanded claw backs if you are disenrolled. Under current statutes, when your enrollment is suspended, typically only future reimbursements are impacted. Under the proposed ruling, your Medicare revocation could potentially be retroactive to the date they believe your non-compliance started. This potentially could allow CMS and its contractors to claw back payments already made for the whole period of non-compliance.
- There are routine ongoing random inspections for both DME and non-DME in areas of the country where there is a higher incidence of fraud (e.g. South Florida). These are no different than JACHO inspections at hospitals which come unannounced
What Providers Should Consider to be Proactive:
- Work with enrollment experts and legal counsel prior to making any organizational or ownership changes.
- Understand all enrollment requirements. Be sure that all the information submitted is 100% accurate.
- Maintain copies of all supporting documents.
- Investigate the demographics of the beneficiary and provider population in your area. Inquire with your local Part B or DME NPI what they mean about the concentration of providers in your area.
- Check the enrollment status of any providers you potentially may share space with. Routinely check the provider status of others who you do share space with.
- Hire outside experts to perform audits on all compliance issues, not just claim submissions.
- Violations and revocations are no longer limited to DME. Thus, staff should be properly prepped and prepared for routine random inspections from carriers involved in either DME and local Medicare enrollment.
- Comments on all these potential changes may be made on the Federal eRule Making Portal at this link
by searching for the Rule CMS-2026-2311
Comments must be received by August 31, 2026
It is clear from this recent CMS Salvo that they are taking fraud and abuse very seriously and that enrollment whether you are a physician or supplier (or both) is one way for them to discourage waste, fraud and abuse.
DME fraud is real. From a personal perspective my Medicare account has been compromised on three separate occasions, by three different out of state DME providers. The most recent resulting from an ER visit, potentially resulting from a hospital employee passing my Medicare information and that of a provider at the hospital to an unscrupulous DME provider. All ethical providers, whether physicians or DME suppliers, should applaud the proactive measures against fraud and abuse. However, CMS needs to hear that these new measures may go too far. Collectively they threaten patients’ access to care, simultaneously adversely impacting the livelihood of hardworking ethical providers. Let your patients know that they should regularly review their Medicare statements and let them know they should feel comfortable reviewing any of your claims and payments with your office. Also inform Medicare and the OIG that their investigations take too long. Delayed action by CMS and OIG rewards criminal activity. Taking two or more years to shut down unscrupulous activity is far too long. Let CMS know that drop shipments of braces should be illegal and reference Operation Brace.
If you or your patients suspect fraud or abuse, do not hessite to contact Medicare at 1800 Medicare, or call the Office of Inspector General at 1800 HHS TIPS.
KevinRoot’s team is ready and willing to provide resources who can assist you with various Medicare compliance measures. If you have any questions, do not hesitate to contact us.
