Home Health Rule May Target Legit Providers, Group Wants Changes

LeadingAge, the American Health Care Association/National Center for Assisted Living and a group of 17 other healthcare entities wrote CMS to warn the agency that the proposed changes to Medicare provider enrollment provisions included in the Calendar Year (CY) 2027 Home Health Prospective Payment System (PPS) Rule could penalize legitimate providers and in turn limit beneficiary access to care.

In the letter, the coalition made clear it backs measures to protect the Medicare Trust Fund and beneficiaries from fraud, waste, and abuse, but not “proposed sweeping changes to Medicare provider enrollment policies, which would significantly broaden the agency’s authority to deny, revoke, or otherwise restrict providers’ participation in the Medicare program, expand enforcement tools without providing the objective standards, clear definitions, and procedural safeguards necessary to ensure that legitimate providers are not mistakenly swept into enforcement actions.”

The coalition’s letter said the foreseeable result of the changes would cause “severe enrollment consequences for legitimate providers based on technical errors, conduct outside their control, or broadly defined third-party associations rather than intentional or egregious misconduct — and when a legitimate provider is removed from Medicare, it is beneficiaries who lose access to care.”

In addition, the proposals also would subject providers to substantial new burdens, not accounted for in the regulatory impact analysis, without cause, the letter said.

As an alternative, the coalition asked CMS to do the following instead:

- Issue Provider Enrollment Changes Through Standalone Rulemaking. Placing program-wide enrollment changes inside a home health payment rule departs from more than two decades of CMS practice and leaves many affected providers — who have no connection to home health and no reason to track that rule — unaware that their Medicare participation is at stake. Since 2003, CMS has established and revised the standards governing Medicare provider enrollment through standalone rulemaking.

- Distinguish Intentional Misconduct from Good-Faith Error. Enrollment revocation is an extraordinarily consequential remedy. Providers should not face essentially the same sanction for a clerical mistake, a documentation deficiency, or conflicting CMS/MAC guidance as actors engaged in deliberate fraud. CMS should adopt materiality and, where appropriate, knowledge or intent standards, including requiring a showing of intent to mislead or a pattern of inaccurate submissions before denial or revocation based on false or misleading information, and should reserve denial and revocation for significant program-integrity risks rather than routine compliance errors.

- Establish Reasonable Due-Diligence Protections for Third-Party Relationships. The proposed rule would sweep a far broader universe of third parties — particularly newly defined managing employees and affiliates — into the basis for denying or revoking a provider’s enrollment. There must be a meaningful nexus between the third party’s conduct and the enrolled provider including whether the provider knew or reasonably could have known of the conduct and whether it presents a current, material risk attributable to the provider.

- Preserve Meaningful Due Process and an Opportunity to Cure. Many of the proposals expand the circumstances in which CMS may deny, revoke, retroactively revoke, preclude, or bar reapplication without giving the provider any opportunity to correct the underlying problem. Providers should be able to correct inaccurate information, cure technical deficiencies, disassociate from a problematic individual or entity, and rebut CMS’s alleged connection between the conduct and the provider before losing enrollment.

Comments or questions? Contact Patrick Connole at pconnole@parkplacelive.com.