As a part of its ongoing effort to reduce fraud and abuse, the Centers for Medicare & Medicaid Services (CMS) announced that effective March 25, newly enrolling and revalidating providers and suppliers will be placed in one of three screening categories-limited, moderate, or high. Each category represents the risk level that CMS estimates the supplier/provider poses to the Medicare system and determines the degree of screening that the Medicare Administrative Contractor (MAC) will perform when processing the enrollment application.
According to a March 3 CMS listserv announcement, screening procedures for the limited-risk category will largely be the same as those currently in use. Providers in the limited-risk category include, among other, physicians, non-physician practitioners (other than physical therapists), and medical groups or clinics.
Screening procedures for the moderate-risk category will include all current screening measures, as well as an unscheduled or unannounced site visit. Moderate-risk providers include revalidating DMEPOS suppliers and home health agencies, as well as physical therapists enrolling as individuals or as group practices, ambulance suppliers, hospice organizations, independent clinical laboratories, community mental health centers, comprehensive outpatient rehabilitation facilities, and portable x-ray suppliers.
Screening procedures for the high-risk category will include all current screening measures, as well as an unscheduled or unannounced site visit and, at a future date, a fingerprint-based criminal-background check. Newly enrolling DMEPOS suppliers and home health agencies will be placed in the high-risk category.
“The Affordable Care Act requires CMS to determine the level of screening to be conducted during provider and supplier enrollment based on the level of risk posed to the Medicare system,” CMS stated in its listserv post. “With the enactment of the Affordable Care Act, we have the increased ability to focus our efforts on prevention, rather than simply acting after the fact. 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.”
To read the final rule published in the Federal Register, visit www.gpo.gov/fdsys/pkg/FR-2011-02-02/pdf/2011-1686.pdf