Patient Protection and Affordable Care Act: Highlights of Program Integrity Provisions Managed Care Delivery System Subcommittee June 9, 2011 1
Provider Screening and Other Enrollment Requirements Provider screening requirements* Disclosure requirements* Temporary moratorium on enrollment of new providers* Compliance programs Reporting of adverse provider actions Enrollment and NPI of ordering or referring providers* Other state oversight Disclosure of Medicare terminated providers and suppliers to State *Included in Final Rules issued on 2/2/11 2
Provider Screening and Enrollment Must screen all enrolled providers Level of screening will depend on risk of fraud, waste, & abuse for provider type Limited risk Verify compliance with applicable federal and/or state requirements License verification Database checks e.g. EPLS, LEIE, SSI master death file Moderate risk All limited risk requirements and On-site visits pre- and post enrollment High risk All limited and moderate risk requirements and Conduct criminal background checks and fingerprinting (states not required to implement until additional guidance is issued CMS seeking input on these provisions comments due by April 4, 2011) 3
Provider Screening and Enrollment Final Level of Required Screening for Medicare Physicians, Non-physicians, Practitioners, Providers and Suppliers TYPE OF SCREENING REQUIRED LIMITED MODERATE HIGH Verification of any provider/supplier-specific X X X requirements established by Medicare Conduct license verifications, (may include X X X licensure checks across States) Database Checks (to verify Social Security X X X Number (SSN); the National Provider Identifier (NPI); the National Practitioner Data Bank (NPDB) licensure; an OIG exclusion taxpayer identification number; death of individual practitioner, owner, authorized official, delegated official, or supervising physician. Unscheduled or Unannounced Site Visits X X Fingerprint-Based Criminal History Record Check of law enforcement repositories X 4
Provider Screening and Enrollment Final Medicare Providers and Suppliers Categories Designated to the Limited Level for Screening Purposes Physician or non-physician practitioners and medical groups or clinics, with the exception of physical therapists and physical therapist groups Ambulatory surgical centers Competitive acquisition program/part B vendors End-stage renal disease facilities Federally qualified health centers Histocompatability laboratories Hospitals, including critical access hospitals Indian Health Service facilities Mammography screening center Mass immunization roster billers Organ procurement organizations Pharmacies newly enrolling or revalidating via the CMS-855B Radiation therapy centers Religious non-medical health care institutions Rural health clinics Skilled nursing facilities 5
Provider Screening and Enrollment Final Medicare Providers and Suppliers Categories Designated to the Moderate Level for Screening Purposes Ambulance suppliers Community mental health centers Comprehensive outpatient rehabilitation facilities Hospice organizations Independent diagnostic testing facilities Independent clinical laboratories Physical therapy including physical therapy groups Portable x-ray suppliers 6
Provider Screening and Enrollment Final Medicare Providers and Suppliers Categories Designated to the High Level for Screening Purposes Prospective (newly enrolling) home health agencies Prospective (newly enrolling) suppliers of DMEPOS 7
Provider Screening and Enrollment Adjustment of risk levels Level of risk must move to high if a payment suspension is imposed (based on credible allegation of fraud) Level of risk must move to high if provider has been excluded in the past 10 years Level of risk must over to high for 6 months following any temporary enrollment moratoria MA may rely on results of screening from: Medicare contractors MA or CHIP agencies from other states Revalidation States must revalidate all enrolled providers every 5 years 8
Provider Screening and Enrollment Disclosures Must collect social security numbers and dates of birth for persons with ownership and/or controlling interest Application Fee $500 for institutional providers, defined as: Nursing facilities ICF/MR Psychiatric RTFs Providers are subject to one application fee if screened by Medicare the state will not collect an application fee 9
Additional Requirements Provisional Period of Enhanced Oversight: HHS may establish a period of between 30 days and 1 year for new providers or categories of providers to be subject to enhanced oversight, including pre-payment review and payment caps. Disclosure Requirements: Medicaid agencies must collect disclosures from disclosing entities, fiscal agents and MCOs new requirements include: Date of birth and Social Security numbers (individuals) Other tax identification number (for corporations) Name, date of birth, social security number of managing employee of disclosing entity 10
Additional Requirements Temporary Moratorium on Enrollment of New Providers: HHS and States may impose moratoria on enrollment of provider types at risk of fraud, waste and abuse. States may avoid HHS moratorium if the moratorium would affect Medicaid recipients access to care. Compliance Programs: HHS is required to establish compliance program requirements and timeline for establishment of core elements. Compliance program is a condition of enrollment for Medicare, Medicaid, and CHIP providers and suppliers. Reporting of Adverse Provider Actions: States must report to HHS adverse actions the States have against providers, according to HHS regulations. 11
Additional Requirements Enrollment and NPI of Ordering or Referring Providers: All ordering and referring physicians and other professionals under the State plan or waiver program must be enrolled in Medicaid as a participating provider. NPIs must be on all claims for payment of ordering and referring physicians and other professionals. Other State Oversight: States may engage in provider screening beyond that specified Disclosure of Medicare Terminated Providers and Suppliers to States: HHS must establish a process for making available to States information about terminations and revocations of providers and suppliers from Medicare and CHIP. 12
Administrative Remedy for Knowing Participation by Beneficiary in Health Care Fraud Scheme HHS may impose administrative penalties on recipients who knowingly participate in a Federal health care fraud offense or a conspiracy to commit a Federal health care fraud offense. Penalty must be commensurate with the offense or conspiracy. Penalties are not specified. 13
Reporting and Returning of Overpayments Providers, suppliers, Medicaid MCOs, Medicare Advantage plans, and PDP sponsors must report and return overpayments to HHS, the State, or a Medicare intermediary or carrier by the later of: 60 days of identification of overpayment, or the due date of the cost report. Treble damages and CMPs up to $50K for knowing failure to return overpayments on time. Knowing and failure to report may also be considered a false claim under the Federal False Claims Act. 14
Suspension of Medicare and Medicaid Payments Pending Investigation of Credible Allegations of Fraud HHS may suspend and the State must suspend payments to individuals or entities based upon credible allegations of fraud, unless HHS/the State determines there is good cause not to suspend payments. Applies to Medicare and Medicaid. 15
Face-to-Face Encounters with Patient Required Before Physicians May Certify Eligibility for Home Health Services and DME under Medicare Prior to certifying/recertifying a Medicare patient for home health or DME, a physician must certify that he/she or other eligible health care professional had a face-to-face (or telehealth) encounter with a patient within: a reasonable period of time (to be determined by HHS) for home health services; 6 months (or other period specified by HHS) for durable medical equipment. Applies to Medicaid for home health (which includes DME) 16
Expansion of the Recovery Audit Contractor (RAC) Program The State must establish a RAC Program consistent with State law by 12/31/2010. RAC must identify overpayments and underpayments. The State must pay RACs on a contingency fee basis for recoveries of overpayments. State appeals procedures must apply. RACs must coordinate with other law enforcement. 17
CMS Guidance on Medicaid RACs Proposed rules issued 11/10 (Notice of Proposed Rulemaking, 6034-P) Required contracts to be operational by 4/1/11 CPI-CMCS Informational Bulletin (CPI-B 11-03) Issued 2/1/11 Final rule (to be issued later this year) will indicate a new implementation date Changed due to states operational issues and ensure states comply with Final Rule 18
Termination of Provider Participation under Medicaid if Terminated under Medicare or Other State Plan The State must terminate or exclude from Medicaid participation any individual or entity that has been terminated from participation in Medicare or from another State's Medicaid program. CMS will issue a State Plan Amendment. 19
Prohibition on Payments to Institutions or Entities Located Outside of the United States The State shall not pay for Medicaid items or services under the State plan or a waiver program to any financial institution or entity located outside the United States. CMS will issue a State Plan Amendment. 20
Overpayments Return of FFP Deadline for the State to return the Federal share of overpayments is extended from 60 days to 1 year for most overpayments. For overpayments resulting from fraud where a final determination of the amount of the overpayment has not been made under an administrative or judicial process, the deadline is extended to 30 days after the date of the final judgment (including any appeal). CMS will promulgate regulations. Effective upon enactment and applies to OPs discovered on & after that date. 21
QUESTIONS? Contact Information: lrock@pa.gov (717)772-4606 22