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PATIENT PROTECTION AND AFFORDABLE CARE ACT ("PPACA"): PROVIDER SCREENING AND ENROLLMENT REQUIREMENTS UNDER MEDICARE, MEDICAID AN

04/15/2010 - 6:00 PM

This installment of Hall Render's Health Law Broadcast series on health care reform is designed to provide you with the insight, analysis and practical suggestions with respect to the various reform initiatives that will affect your organization.

PATIENT PROTECTION AND AFFORDABLE CARE ACT ("PPACA"): PROVIDER SCREENING AND ENROLLMENT REQUIREMENTS UNDER MEDICARE, MEDICAID AND CHIP

Under the PPACA , enacted March 23, 2010, providers and suppliers participating in or enrolling in the Medicare, Medicaid and CHIP programs will be subject to new provisions pertaining to screening and enrollment requirements. For purposes of this section, the terms provider and supplier refer to individuals and entities providing Medicare services. Specifically, these new program integrity provisions include: (1) screening of providers and suppliers; (2) enhanced oversight; (3) disclosure requirements; (4) imposition of temporary enrollment moratoria; and (5) establishment of compliance programs.

Screening of Providers and Suppliers

No later than six (6) months after the enactment of PPACA, procedures will be developed to identify a screening process for providers and suppliers. The level of screening for each provider/supplier category will be based on the risk of fraud, waste, and abuse as determined by the Secretary of the Department of Health and Human Services (HHS). The screening process must include a licensure check, which may be across States. In addition, the screening process may include:

A criminal background check;

Fingerprinting;

Unscheduled and unannounced site visits, including pre-enrollment site visits;

Database checks, across States; and

Such other screening as deemed appropriate by the Secretary.

The screening process will apply to (1) new providers and suppliers one year after the PPACA enactment (a provider or supplier is considered "new" if not currently enrolled on March 23, 2010); (2) currently enrolled providers and suppliers two years after the PPACA enactment; and (3) revalidation of enrollment of providers and suppliers effective 180 days after the PPACA enactment. By three years after the enactment of PPACA, provider and suppliers will not be permitted to enroll or enroll if such provider or supplier has not been screened.

Fee Assessment and Hardship Exception

No fee for individual providers: The PPACA originally imposed a $200 screening fee for each individual provider, such as physicians, physician assistants, nurse practitioners, and clinical nurse specialists. This provision was deleted by later amendment.

Institutional providers: A screening fee will be assessed for institutional providers, such as hospitals and skilled nursing facilities, in the amount of $500 for 2010. This amount will be adjusted by the consumer price index each year beginning in 2011.

Hardship exception: The Secretary may waive the application fee for providers enrolled in a State Medicaid program for whom the State demonstrates that imposition of a fee would create a hardship and impede beneficiaries' access to care.

Enhanced Oversight for New Providers and Suppliers

Procedures will be developed to categorize providers and suppliers that may require enhanced oversight. This provisional period of oversight will continue for a period of thirty (30) days up to one year after initial enrollment and could include payment limits or prepayment review.

Increased Disclosure Requirements

Effective one year after enactment of the PPACA, any provider or supplier that has or had an affiliation with another provider or supplier that has (i) uncollected debt; (ii) suspension of payments from any Federal health care program; (iii) been excluded from participating in a Federal health care program; or, (iv) had its billing privileges denied or revoked, must disclose this information when submitting an application for enrollment or revalidation.

Authority to Adjust Payments

This provision allows the Secretary to make adjustments to payments to applicable providers or suppliers that have the same Tax Identification Number as a provider or supplier that has outstanding, past-due obligations. This authority exists regardless of whether the applicable provider or supplier has a different NPI or billing number from the obligated (past-due) provider or supplier.

Temporary Moratorium on Enrollment of New Providers

A temporary moratorium on enrollment may be applied to new provider/supplier categories as necessary by the Secretary to prevent or reduce fraud, waste, and abuse.

Compliance Programs

Under this provision, providers and suppliers must, as a condition for enrollment in Medicare/Medicaid, develop and implement a compliance program. The core elements of the compliance program and a timeline for implementation will be determined by the Secretary.

Current and potential Medicare/Medicaid providers and suppliers should gain a clear understanding of the above provisions and the impact each may have on a provider's or supplier's enrollment in the Medicare and Medicaid programs. If you have any questions regarding the foregoing, please feel free to contact Regan Tankersley at (317) 977-1445 or rtankersley@hallrender.com; Brian Jent at (317) 977-1402 or bjent@hallrender.com; or your regular Hall Render attorney.

Visit our Health Law Broadcast at hallrender.com/reform for a comprehensive listing of health care reform resources. Also sign up for health care reform alerts and periodic updates as we continue to monitor this important issue.

This information is intended for general information purposes only and does not and is not intended to constitute legal advice. The reader must consult with legal counsel to determine how laws or decisions discussed herein apply to the reader's specific circumstances.

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