On Sept. 5, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that “strengthens the agency’s ability to stop fraud before it happens by keeping unscrupulous providers and suppliers out of our federal health insurance programs,” including Medicare, Medicaid and the Children’s Health Insurance Programs (CHIP) (collectively, FHCP). The final rule, program integrity enhancements to the provider enrollment process (CMS-6058-FC) (final rule), creates several new revocation and denial authorities to strengthen CMS’ efforts to stop fraud and abuse, including a new “affiliations” authority that allows CMS to identify individuals and organizations that pose an undue risk of fraud, waste and abuse based on their relationships with other previously sanctioned entities. For example, a currently enrolled or newly enrolling organization that has an owner or managing employee who is “affiliated” with another previously revoked organization can be denied enrollment in the FHCPs or, if already enrolled, can have its enrollment revoked because of the problematic affiliation. The final rule takes effect on Nov. 4.

The final rule, which is a first-of-its-kind action by CMS to stop fraudsters before they get paid, marks a critical step forward in CMS’ longstanding fight to end “pay and chase” in federal health care fraud efforts and replace it with effective and proactive measures. This progressive action is part of the Trump administration’s ongoing effort to safeguard taxpayer dollars and protect the integrity of the CMS programs that millions rely on. CMS hopes to address gaps and vulnerabilities in the provider enrollment system when it comes to identifying “bad actors”—those who have real and demonstrable histories of conduct and relationships that pose an undue risk to taxpayers, patients and program, beneficiaries—within Medicare, Medicaid and CHIP.