CMS Screening Protocols for Enrolling and Revalidating Providers Effective March 23

The Affordable Care Act of 2010 required the Centers for Medicare and Medicaid Services (CMS) to establish standards for screening Medicare, Medicaid, and CHIP providers, suppliers and eligible professionals based upon the level of risk associated with the category of provider.  CMS has identified three categories of risk—“limited,” “moderate” and “high”—and the type of providers, suppliers and eligible professionals to be considered under each risk level.  Based upon the designation, the providers and suppliers can be subject to varying levels of screening, including unscheduled and unannounced site visits, criminal background checks and fingerprint submissions.

CMS will impose a screening fee on all new enrollment and revalidation applications to cover the costs of screening and integrity efforts.  The Affordable Care Act establishes a $500 fee for providers and suppliers ($200 for individual practitioners) in 2010 as a starting base and the amount will be adjusted each subsequent year by the percentage of change in the Consumer Price Index.

The initial phase of these new screening protocols will take effect on March 23, 2011, and will be applicable to newly enrolling and any currently enrolled providers, suppliers or eligible professionals that must submit for revalidation on or after March 23, 2011 and before March 23, 2012.  The procedures will be applicable to all other currently enrolled Medicare, Medicaid, and CHIP providers, suppliers, and eligible professionals beginning on March 23, 2012.  In no case may a provider or supplier be enrolled without being screened after March 23, 2013.

CMS may exclude individuals who knowingly make—or cause to be made—a false statement, omission, or misrepresentation of a material fact on applications or contracts to participate in a federal health care program.

CMS may impose a temporary six-month moratorium on enrollment of new providers and the establishment of new practice locations (not a change) to prevent or combat fraud, waste, or abuse, unless the State determines that the imposition of such temporary moratorium would adversely impact beneficiaries’ access to medical assistance.

This post was contributed by Charles Dunham.