Effective March 25, 2011, providers enrolling in Medicare will be categorized into one of three screening levels – limited, moderate, or high – that represent the amount of risk they pose to the Medicare system. Physicians are part of the limited screening level as they pose little risk in terms of committing Medicare fraud.
The Affordable Care Act required the Centers for Medicare and Medicaid Services (CMS) to develop these new screening categories in order to reduce fraud, waste, and abuse and increase the focus on prevention. The risk levels are also based on claims data, as well as insights from studies by the U.S. Office of Inspector General and the Attorney General’s office.
Even though they are in the limited level, physicians must continue to meet all applicable federal and state requirements for Medicare provider enrollment. Licensure checks will continue but may now include checks across states. Database checks (both pre- and post enrollment) also will be expanded and include the Social Security Administration, NPI database, and National Practitioner Data Bank.
Moderate level screening requirements include all measures in the limited screening category, and the addition of an on-site visit conducted by the contractor. Physical therapists, existing DMEPOS suppliers, and home health agencies fall into this category.
High level screening requirements, which apply to newly enrolling home health agencies and DMEPOS suppliers, include all procedures in the moderate level, unscheduled and unannounced site visits, and possibly a finger-printing based criminal background check. Due to significant feedback, final details of the finger-printing requirement have been delayed and CMS is accepting comments on this until April 4, 2011.
The
March 8, 2011, Provider Bulletin contains a complete list of the providers and suppliers that fall into each screening category.