Join ADAMember Log In

New CMS provider screening procedures effective March 25

Washington—The Centers for Medicare & Medicaid Services will apply newly effective risk-based screening requirements to providers and suppliers wanting to enroll or continue participating in public health insurance programs serving children, aged, disabled and low income recipients.

Congress in the 2010 health reform law mandated new application, enrollment and screening procedures to combat fraud, waste and abuse.

“The use of risk categories and associated screening levels will help ensure that only legitimate providers and suppliers are enrolled in Medicare, Medicaid and CHIP, and that only legitimate claims are paid,” said CMS. “Effective Friday, March 25, 2011, newly-enrolling and revalidating providers and suppliers will be placed in one of three screening categories—limited, moderate or high.”

Dentists are in the limited risk level, lowest of the three, which means they will be screened to:

  • Ensure that they meet all applicable federal regulations and state requirements regarding enrollment requirements;
  • verify licensure, and
  • ensure that they continue to comply with applicable enrollment criteria.

The American Dental Association submitted comments on CMS’ Sept. 23, 2010 notice of proposed rulemaking. The final rule, Medicare, Medicaid, and Children’s Health Insurance Programs; Additional Screening Requirements, Application Fees, Temporary Enrollment Moratoria, Payment Suspensions and Compliance Plans for Providers and Suppliers, was published Feb. 2, 2011 in the Federal Register.

Selected Provisions of the Final Rule

Screening: Moderate and high risk providers and suppliers will be subject to the limited level procedures, on-site inspections and certain fingerprinting and criminal background check requirements. States may impose more stringent screening requirements. Under certain circumstances, CMS and state Medicaid agencies may assign a provider or supplier to a higher risk level, for example, if payment has been suspended based on a credible allegation of fraud, waste or abuse. A state Medicaid agency may assign a provider to a higher risk level if the provider has an existing Medicaid overpayment.

Application fee: A $500 application fee will be required of an institutional provider that submits a Medicare enrollment application using form CMS-855B (not including physician and nonphysician practitioner organizations), CMS-885A or CMS-855S. A dentist or small group dental practice would be excluded from paying the application fee.

Payment suspension: Medicare payments may be suspended if there is reliable information that an overpayment exists, that payments to be made may not be correct, and in cases involving a credible allegation of fraud. Such allegations may arise from any source, including but not limited to fraud hotline complaints, claims data mining, patterns identified through provider audits, civil False Claims Act cases and law enforcement investigations. Medicare payments may be offset or recouped if the provider or supplier has been overpaid. States must suspend Medicare payments during pending investigation of a credible allegation of fraud.

Temporary moratoria: If CMS determines there is a significant potential for fraud, waste or abuse, the agency may impose a temporary moratorium on the enrollment of new Medicare and Medicaid providers and suppliers of a particular type or the establishment of new practice locations of a particular type in a particular geographic area.

Denial or termination of enrollment: A state Medicaid program must deny or terminate enrollment of any provider who has had billing privileges revoked for cause (including fraud, integrity or quality issues) under Medicare or Medicaid or the CHIP of any state. This applies regardless of whether the provider submits claims or is an ordering/referring provider. When a state Medicaid agency terminates or revokes a provider’s billing privileges, CMS may revoke Medicare enrollment and billing privileges. A state Medicaid agency must deny or terminate enrollment in certain cases involving failure to cooperate with screening or to submit timely and accurate information and in certain cases involving conviction for criminal offenses.

Ordering/referring Medicaid providers: Under the health reform law, states must require all ordering or referring providers to be enrolled under a Medicaid state plan or waiver of the plan as a participating provider, and the National Provider Identifier of any ordering/referring provider must be included on a claim for payment. An ordering/referring provider may prescribe drugs, order other covered items, send a beneficiary’s specimens to a lab for testing or refer a beneficiary to another provider or facility for covered services.

Fraud and abuse compliance program: The health reform law requires Medicare, Medicaid and CHIP providers and suppliers to implement fraud and abuse compliance programs containing certain “core elements” as a condition of enrollment. Future regulations will establish the required core elements of compliance programs for particular categories of providers and suppliers.

Preparing for the new requirements

Dentists should be alert for further federal and state guidance and may wish to take certain steps to prepare for the new requirements. For example:

  • Review claims procedures to ensure that claims under Medicare, Medicaid, and CHIP are properly billed;
  • review internal mechanisms to detect and correct billing errors;
  • ensure that all enrollment and screening information is accurate and submitted in a timely manner;
  • be alert for evidence of provider identity theft, and
  • review existing fraud and abuse compliance programs in advance of release of the required “core elements.”

In 2000, the Office of Inspector General of the U.S. Department of Health and Human Services (OIG) identified the following components of an effective compliance program for individual and small group practices:

  • Conducting internal monitoring and auditing;
  • implementing compliance and practice standards;
  • designating a compliance officer or contact;
  • conducting appropriate training and education;
  • responding appropriately to detected offenses and developing corrective action;
  • developing open lines of communication, and
  • enforcing disciplinary standards through well-publicized guidelines.

The OIG said that a compliance program can enhance a practice’s focus on patient care and prevent problems by:

  • Increasing the accuracy of documentation;
  • speeding and optimizing proper payment of claims;
  • minimizing billing mistakes;
  • reducing the chances of an audit;
  • avoiding conflicts with self-referral and anti-kickback statutes;
  • showing that a practice is making good faith efforts to submit claims appropriately, and
  • communicating to employees that while mistakes will occur, employees have a duty to report erroneous or fraudulent conduct so that it may be corrected.