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CMS lays ground rules for provider screening, fingerprinting for fraud risk

June 16, 2015
by Megan Combs, Associate Editor
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The Centers for Medicare and Medicaid Services (CMS) is cracking down on fraud both at the organizational and individual level. This week, it released a guidance document on Section 6401 of the Affordable Care Act, which covers provider screening and other enrollment requirements under Medicare, Medicaid and the Children's Health Insurance Program.

The guideline states that by March of 2016, all of a state's Medicaid providers have to be screened and ranked as having a "high," "moderate," or "limited" risk of defrauding the program. If a provider is determined to be a high risk, "the provider an any person with five percent direct or indirect ownership interest in the provider, must submit fingerprints and undergo a criminal background check," according to an article written by Akerman LLP Health Law.

State Medicaid agencies are charged with determining which providers and which categories of providers provide a high risk of fraud, waste or abuse to the Medicaid program. For example, one category that is determined high risk are "newly enrolled home health agencies, newly enrolled durable medical equipment, prosthetics, orthotics and supplies suppliers," the Akerman article states.

State Medicaid agencies must then terminate or deny enrollment of a provider if that provider, or any person with a five percent or greater direct or indirect ownership interest who is required to submit fingerprints fails to submit them in 30 days. 

Download this FAQ sheet (PDF) from CMS to get more information.

On a related note, CMS recently conducted a survey on whether to eliminate Certificate of Medical Necessity (CMN) and Durable Medical Equipment Information forms as required documents to determine medical necessity. The survey ended June 12, but CMS said it was looking for ways to reduce burden because CMN documents usually conflict with medical records.