New Providers and New Approaches to Program Integrity
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1 New Providers and New Approaches to Program Integrity National Association of Medicaid Directors November 3, 2015 Jonathan Morse, JD Deputy Center Director, Center for Program Integrity
2 Provider Enrollment is a Program Integrity Function CMS has aligned responsibility for Medicare and Medicaid provider enrollment within the Center for Program Integrity (CPI). This change: Reflects CMS view that provider enrollment is a program integrity function. Decreases provider burden. Aligns Medicare and Medicaid provider enrollment practices to the greatest extent possible. 2
3 Provider Screening as a Program Integrity Strategy Why Screen Providers? Protect beneficiaries from bad actors. Prevent improper payments to ineligible providers. Foundational to delivery system reform. 3
4 High Noncompliance with Provider Screening & Enrollment Regulations Many states need assistance in achieving full compliance, including: Collecting complete ownership and control disclosures (42 C.F.R ). Revalidating all providers by the March 25, 2016 deadline ( ). Denying claims missing the NPI of the ordering, referring, or prescribing provider ( ). Terminating providers terminated from Medicare or another state s Medicaid Program or CHIP ( ). 4
5 Revalidation Deadline: March 2016 States must revalidate Medicaid providers by 3/25/2016 (42 C.F.R ). The revalidation effort protects the Medicaid program by ensuring only providers that continue to meet Medicaid rules and regulations are enrolled. Applies to all providers enrolled as of 3/25/
6 Noncompliance is increasing Improper Payment Rate National Medicaid and CHIP Improper Payment Error Rates (PERM): 2013: 5.8% 2014: 6.7% Noncompliance with provider enrollment revalidation requirements is driving the increase in error rate in many states. The 2015 Medicaid and CHIP Improper Payment Rate will be published in mid- November. 6
7 PERM and CPI State Program Integrity Reviews Alignment Moving forward, CPI will make changes to the format of its State Program Integrity Reviews to: Align with the PERM review cycle to the greatest extent possible. Include an assessment of states implementation of PERM Corrective Action Plans. In FY 2016, this work will encompass reviewing the CAPs submitted by the Cycle 2 PERM states. 7
8 Reciprocal Provider Terminations If Medicare or another state s Medicaid program terminates a provider or supplier s billing privileges on or after January 1, 2011, the state must likewise terminate billing privileges under 42 C.F.R If a state terminates a provider s billing privileges and all appeal rights are exhausted, the provider likewise may be revoked from Medicare under (a)(12). 8
9 Reducing State & Provider Burden Under certain conditions, the state should rely on Medicare s enrollment data for dually enrolled providers: Site Visits Revalidations Collection of application fees Fingerprinting Results
10 Support for your State CMS is developing a Medicaid program integrity manual similar to Medicare program integrity manual to address common questions and provide more detailed guidance. PECOS basics training three times a year. Provider enrollment educational webinars with states (early focus on PERM Cycle 2 states).
11 Support for your State Planning is underway for changes to CMS enrollment systems, including PECOS, NPPES, and APS (provider screening tool). Changes will accommodate key pieces of Medicaid enrollment data, provide access to all states to view Medicare enrollment data, and create real-time data services.
12 CPI is your POC for Provider Screening & Enrollment Assistance understanding and complying with 42 C.F.R 455 Subparts B & E. Access requests for: Medicare Provider Enrollment data. Medicare For Cause Revocations data. Medicaid Terminations data. Requests for hardship and access waivers. 12
13 Medicaid Program Integrity CMS Points of Contact Provider Enrollment: Hardship and Access Waivers: Terminations: PECOS or the Tibco MFT Server: 13
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