WASHINGTON, DC – Today, Representative Jim McDermott (D-WA) sent a letter to the Centers for Medicare and Medicaid Services (CMS), urging them to revisit the classification of certain regulations.  The letter expresses concern that unintended loopholes have caused many successful health care fraud prosecutions to be overturned, costing the Medicare trust fund millions of dollars. 

The problem lies in a classification: some Medicare regulations are deemed “conditions of enrollment,” while others are “conditions of payment,” and only the latter can form the basis for a False Claims Act action. Under the agency’s existing guidelines, many regulations that impact beneficiaries’ quality of care are classified as conditions of enrollment.  This means courts sometimes have no choice but to overturn False Claims Act judgments even where providers have committed egregious violations of regulations intended to protect Medicare beneficiaries.
 
The letter also urges the agency to review its claims forms and enrollment forms to make sure that both contain language that is legally sound and informs providers that there may be penalties under the False Claims Act if the provider violates applicable statutory and regulatory provisions.

If language needs to be changed in order for providers and suppliers to be held accountable,” said McDermott, “I suggest that these changes be made to ensure that the False Claims Act retains its potency as a tool to prosecute serious health care fraud offenses.” 

The full letter can be read here.

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