Medicare Enrollment and Disenrollment: Avoiding Citations and Fraud, Waste, and Abuse
Jeannine LeCompte, Compliance Research Specialist
The Centers for Medicare and Medicaid Services (CMS) is obliged to investigate any facility where it appears that a recipient’s Medicare Advantage/Part D enrollment has been terminated and the beneficiary alleges that they did not request or understand that this was done.
The CMS investigation will demand of the facility that it provide documentation to prove that it “appropriately assisted” the recipient with the coverage change. In the case of written assent, the facility will also have to prove that the recipient was of a sufficient cognitive level to have understood the implications of the change, or that his or her representative did.
42 CFR §483.15(a)(2) states that the facility must not require residents or potential residents to waive their rights to Medicare or Medicaid. Surveyor guidance at F620 in Appendix PP of the SOM clarifies that facilities must not seek a direct or indirect waiver of rights to Medicare or Medicaid benefits. In addition, any failure by a facility to allow residents to receive coverage of needed drugs in terms of the Part D plan of their choosing could constitute a violation of the facility’s pharmacy obligations.
It is considered fraud, waste, or abuse of government funds for a facility representative to encourage a resident to switch Medicare plans for the convenience of the facility. It is also considered fraud, waste, or abuse to knowingly admit a resident who does not have a contract with a specific insurance provider—with the intention to persuade the resident to switch Medicare plans upon admission.
Avoiding such allegations can be negated by facilities ensuring that they are members of as many insurance networks as possible. In addition, it is important that the resident or their representative is made fully aware upon admission—and in writing—of what is covered under their Medicare or Medicare Advantage plan.
In this regard, pharmacy selection can be problematic. If the facility’s pharmacy does not have a contract with the resident’s Part D provider, find an alternate pharmacy, or immediately request the existing pharmacy to enroll as a provider for the resident’s Part D plan.
Every referral’s insurance should be screened prior to admission. If the facility is not a preferred provider for the Medicare Advantage Plan, the resident should be made aware that their out-of-pocket costs for the stay at the facility may be high and an alternate facility should be considered.
Avoiding such complications, and their potential legal implications, should be a matter of policy for any facility wanting to stay in business.
