The Centers for Medicare and Medicaid Services (CMS) released final rules on February 2 to strengthen program integrity under Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP).   The final rules require state Medicaid/CHIP agencies to screen providers before enrollment, to re-screen enrolled providers periodically, and to suspend payments pending the outcome of investigations of potential fraud.  States must perform criminal background checks on high risk providers such as suppliers of durable medical equipment (DME); check other federal databases on providers, practitioners, owners, and managing employees sanctioned for improper billing; impose targeted moratoria on new enrollments if necessary to combat fraud; and suspend payments based on credible allegations of fraud from a hotline complaint, data mining, audit, litigation, or law enforcement investigation. States are designing administrative procedures and Medicaid Management Information System (MMIS) functionality to implement the new requirements, which emanate from five provisions of the federal health care reform law, proposed rules that CMS published on September 23, and public comments on the proposed rules that were submitted by over 300 state, local, and private organizations. Recommendations adopted by CMS in the final rules include clarification of numerous definitions and procedural requirements in the proposed rules. The final rules confirm that Medicare provider screening will suffice for Medicare/Medicaid dually enrolled providers; Medicaid managed care organizations may use different, equivalent screening procedures to ensure the integrity of their provider networks; and address key concerns raised by school districts.  

About Tom Entrikin

A former policy specialist with the U.S. Health Care Financing Administration (now Centers for Medicare & Medicaid Services (CMS)), Tom Entrikin has vast experience providing technical assistance to states on Medicaid eligibility, coverage, and reimbursement; provider certification and enrollment; program integrity; recovery of third party liabilities; Medicaid Management Information System (MMIS) performance specifications and operations; interagency agreements; contracts with managed care organizations; and Medicaid waiver programs.

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