New Providers and New Approaches to Program...
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New Providers and New Approaches to Program Integrity Jonathan Morse, JD Deputy Center Director, Center for Program Integrity National Association of Medicaid Directors November 3, 2015
Transcript of New Providers and New Approaches to Program...
New Providers and New Approaches to Program Integrity
Jonathan Morse, JDDeputy Center Director,
Center for Program Integrity
National Association of Medicaid Directors
November 3, 2015
• CMS has aligned responsibility for Medicare and Medicaid provider enrollment within the Center for Program Integrity (CPI).
• This change:– Reflects CMS’ view that provider enrollment is a
program integrity function.– Decreases provider burden.– Aligns Medicare and Medicaid provider enrollment
practices to the greatest extent possible.
Provider Enrollment is a Program Integrity Function
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Why Screen Providers?• Protect beneficiaries from bad actors.• Prevent improper payments to ineligible
providers.• Foundational to delivery system reform.
Provider Screening as a Program Integrity Strategy
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Presenter
Presentation Notes
The purpose of this revalidation requirement in Medicaid is the same as it purpose in Medicare: to keep bad actors out of each program. Bad actors steal taxpayer dollars, harm beneficiaries, and undermine CMS efforts to reduce costs, improve quality, and raise population health. Recovering taxpayer dollars lost to bad actors is very difficult; “paying and chasing” bad actors is a far less effective strategy than identifying them as soon as possible and terminating their participation. The purpose of the regulatory requirements at 42 CFR 455 Subparts B & E is to: Protect beneficiaries from bad actors Prevent improper payments to ineligible providers
• Many states need assistance in achieving full compliance, including:– Collecting complete ownership and control
disclosures (42 C.F.R § 455.104).– Revalidating all providers by the March 25,
2016 deadline (§ 455.414).– Denying claims missing the NPI of the
ordering, referring, or prescribing provider (§ 455.440).
– Terminating providers terminated from Medicare or another state’s Medicaid Program or CHIP (§ 455.416).
High Noncompliance with Provider Screening & Enrollment Regulations
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Presentation Notes
Based on CPI Program Integrity Reviews and Payment Error Rate Measurement (PERM) Reviews, CMS finds major areas of noncompliance
• States must revalidate Medicaid providers by 3/25/2016 (42 C.F.R § 455.414).
• The revalidation effort protects the Medicaid program by ensuring only providers that continue to meet Medicaid rules and regulations are enrolled.
• Applies to all providers enrolled as of 3/25/2011.
Revalidation Deadline: March 2016
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• National Medicaid and CHIP Improper Payment Error Rates (PERM):– 2013: 5.8%– 2014: 6.7%
• Noncompliance with provider enrollment revalidation requirements is driving the increase in error rate in many states.
• The 2015 Medicaid and CHIP Improper Payment Rate will be published in mid-November.
Noncompliance isincreasing Improper Payment Rate
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Presenter
Presentation Notes
Based on CPI Program Integrity Reviews and Payment Error Rate Measurement (PERM) Reviews, CMS finds major areas of noncompliance
Moving forward, CPI will make changes to the format of its State Program Integrity Reviews to:• Align with the PERM review cycle to the greatest
extent possible.• Include an assessment of states’
implementation of PERM Corrective Action Plans. – In FY 2016, this work will encompass reviewing
the CAPs submitted by the Cycle 2 PERM states.
PERM and CPI State Program Integrity Reviews Alignment
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Presenter
Presentation Notes
Essentially, CPI will review a state’s ability to take administrative actions to reduce errors that cause improper Medicaid and CHIP payments as outlined in its CAP Cycle 2 States: Alabama, California, Colorado, Georgia, Kentucky, Maryland, Massachusetts, Nebraska, New Hampshire, New Jersey, North Carolina, South Carolina, Rhode Island, Tennessee, Utah, Vermont, and West Virginia
Reciprocal Provider Terminations
• If Medicare or another state’s Medicaid program terminates a provider or supplier’s billing privileges on or after January 1, 2011, the state must likewise terminate billing privileges under 42 C.F.R § 455.416.
• If a state terminates a provider’s billing privileges and all appeal rights are exhausted, the provider likewise may be revoked from Medicare under §424.535(a)(12).
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Presenter
Presentation Notes
Talking point: Medicare would only revoke based on State terminations that were “for cause” – that is, issues related to fraud, integrity or quality
• Under certain conditions, the state should rely on Medicare’s enrollment data for dually enrolled providers:
•Site Visits•Revalidations•Collection of application fees•Fingerprinting Results
Reducing State & Provider Burden
Presenter
Presentation Notes
TALKING POINT: Under Subpart E states may rely on Medicare’s screening (455.410). CPI has been working to define clearly how states should use PECOS to fulfill screening requirements and offset burden to the states. This should impact burden for states to comply in the categories you see here.
• CMS is developing a Medicaid program integrity manual similar to Medicare program integrity manual to address common questions and provide more detailed guidance.
• PECOS basics training three times a year.
• Provider enrollment educational webinars with states (early focus on PERM Cycle 2 states).
Support for your State
• Planning is underway for changes to CMS enrollment systems, including PECOS, NPPES, and APS (provider screening tool).
• Changes will accommodate key pieces of Medicaid enrollment data, provide access to all states to view Medicare enrollment data, and create real-time data services.
Support for your State
• Assistance understanding and complying with 42 C.F.R § 455 Subparts B & E.
• Access requests for: – Medicare Provider Enrollment data.– Medicare For Cause Revocations data.– Medicaid Terminations data.
• Requests for hardship and access waivers.
CPI is your POC for Provider Screening & Enrollment
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Medicaid Program Integrity CMS Points of Contact
Provider Enrollment: [email protected]
Hardship and Access Waivers: [email protected]
Terminations: [email protected]
PECOS or the Tibco MFT Server:[email protected]
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