CMS seeks new powers to remove ‘problematic’ Medicare providers

 CMS wants to raise Medicare home health payments by 2.4% in 2027 while arming itself with sweeping new authority to remove “problematic” and noncompliant providers — and recoup their payments — across the entire Medicare program.

The CY 2027 Home Health Prospective Payment System proposed rule, issued July 1, pairs a $420 million payment increase for home health agencies with a program integrity package the agency estimates would save about $82 million a year. The proposal would reverse the 1.3% cut CMS finalized for 2026, driven largely by the agency declining to impose a new permanent behavioral adjustment this year.

The enrollment provisions — though housed in a home health rule — would reach every Medicare provider and supplier type, hospitals included.

“These proposals would give CMS stronger tools to protect Medicare beneficiaries and taxpayer dollars from fraud, waste and abuse,” CMS Administrator Mehmet Oz, MD, said in a news release. “The Trump Administration is committed to ensuring only qualified providers and suppliers participate in Medicare while preserving access to high-quality care for patients across the country.”

Eight things to know: 

1. CMS wants broader authority to revoke Medicare enrollment. CMS is proposing several new grounds for denying or revoking Medicare enrollment, including when a provider or supplier is deemed to present a high risk of fraud, waste and abuse because it operates in an area with an excessive concentration of providers or suppliers. The agency also proposes denying or revoking enrollment for providers convicted within the past 10 years of misdemeanors related to sexual assault or financial misconduct.

2. CMS could recover more money from noncompliant providers. The agency proposes making all Medicare enrollment revocations retroactive to the date a provider fell out of compliance, allowing it to recover payments already made rather than only those made after a revocation notice. The change would prevent noncompliant providers from retaining Medicare payments they were not entitled to receive, according to CMS. 

3. The proposal includes a 2.4% payment increase for home health agencies. CMS estimates Medicare payments to home health agencies would increase by about 2.4%, or $420 million, in 2027. The update reflects a proposed 2.1% payment increase and a 0.3% adjustment related to fixed-dollar loss payments.

4. A temporary 3% pay cut would continue. CMS is proposing another temporary 3% reduction to the national standardized payment rate as it continues recouping retrospective overpayments tied to implementation of the Patient-Driven Groupings Model. The agency is not proposing an additional permanent payment adjustment for 2027 after determining more recent utilization changes may reflect factors beyond the payment model itself.

5. CMS wants to expand access to palliative care at home. The agency emphasized that skilled palliative care services can already be provided under the Medicare home health benefit for eligible patients with serious illnesses. CMS also plans to issue additional guidance after publication of the final rule to encourage broader use of community-based palliative care before patients qualify for hospice.

6. Home health quality data could be reported months sooner. CMS proposes shortening the Outcome and Assessment Information Set submission deadline from 4.5 months to 45 days. The agency estimates the change would make publicly reported home health quality information available up to three months sooner.

7. Home health agencies would see additional payment model updates. CMS also proposes recalibrating Patient-Driven Groupings Model case-mix weights, updating low utilization payment adjustment thresholds, revising comorbidity adjustment subgroups and updating outlier payment policies for 2027.

8. The rule includes several other Medicare policy changes. Additional proposals would expand Medicare coverage for certain home infusion pumps and drugs beginning in 2027, revise home health quality reporting requirements, seek public input on a home health-specific wage index and require durable medical equipment suppliers participating in the competitive bidding program to report the country of origin for certain products.

Click here to access the 269-page proposed rule.

https://www.beckershospitalreview.com/finance/cms-seeks-new-powers-to-remove-problematic-medicare-providers-8-things-to-know/