CMS to Begin Using New Risk-Based Screening System for Enrolling Providers/Suppliers

In follow-up to its February 2, 2011 final rule, CMS will implement a risk-based screening system for newly enrolling and revalidating providers and suppliers in the Medicare program on March 25, 2011. Under this new system, as required by PPACA, all providers and suppliers will be assigned to one of three screening categories—limited, moderate, and high. These categories represent the level of risk for fraud, waste, and abuse to the Medicare program for the particular category of provider/supplier, and determine the degree of screening to be performed by the Medicare Administrative Contractor (MAC) that will process the enrollment applications.

Providers/suppliers in the “limited” screening category will include, but not be limited to, physicians, ASCs, hospitals, and SNFs. Providers/suppliers in the “moderate” screening category will include ambulance service suppliers, community mental health centers, hospices, IDTFs, and physical therapists enrolling as individuals or as group practices. “High” risk providers/suppliers include newly-enrolling DMEPOS suppliers and newly-enrolling home health agencies.

The enrollment screening procedures used by the MACs will vary depending upon the three categories described above. Screening procedures for the “limited” screening category will essentially be the same as those currently in use, including licensure verification and database checks, such as NPI and Social Security number verification. For the “moderate” screening category, screening procedures will include all current screening measures, as well as a site visit. For the “high” screening category, screening procedures will include all current screening measures, a site visit and, in the future, a fingerprint-based criminal background check of law enforcement repositories.

For additional information, please contact Leeanne R. Coons at lcoons@kdlegal.com.