Medical Monitoring Program: PPACA and CMS Final Recommended Guidelines vs. Rules: New License Monthly Screening Requirements

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1 PPACA and CMS Final Recommended Guidelines vs. Rules: New License Monthly Screening Requirements The Patient Protection and Affordable Care Act of 2010, as amended by the Health Care and Education Reconciliation Act of 2010 (collectively, the PPACA ), contains numerous provisions related to health care fraud and abuse and program integrity. The ACA went into effect January 1, The CMS Final Guidelines and Rules take effect March 25, The fraud and abuse provisions will have a significant impact on the compliance programs of health care organizations. The overall effect of the new law is to require healthcare organizations to conduct more regular (at least monthly) screening and monitoring of their employees participation status during employment: 1) For licensed healthcare employees: Monthly verification with the State licensing board. 2) For licensed and non-licensed healthcare employees: Monthly screening for exclusions, sanctions and disciplinary actions on the State and Federal level. Provider Screening and Monitoring Sections: Section 6501 PPACA CMS Provisions. Termination of provider participation under Medicaid if terminated under Medicare or other State plan. Requires States to terminate individuals or entities from their Medicaid programs if the individuals or entities were terminated from Medicare or another State s Medicaid program. (PPACA CMS Provisions p.50) Section 6502 PPACA CMS Provisions. State Medicaid agencies must exclude any individual or entity that owns, controls or manages an entity that has failed to repay delinquent overpayments; is suspended, excluded or terminated from participation in any Medicaid program; or is affiliated with an individual or entity that has been suspended, excluded or terminated from Medicaid. (PPACA CMS Provisions p.50) CMS Applicable Rules and Guidelines: To ensure that only qualified providers and suppliers remain in the Medicare fee-forservice (FFS) program, we require that Medicare contractors review State licensing board data on a monthly basis to determine if providers and suppliers remain in compliance with State licensure requirements. (HHS/CMS Final Rules (1/24/2011) p.20)

2 According to the CMS Final Guidelines/Rules on ACA, it is already required that Medicare contractors ensure that every provider or supplier meets any applicable Federal regulations or State requirements, including applicable licensure requirements for the provider or supplier type prior to making an enrollment determination. In addition, we also require that Medicare contractors conduct monthly reviews of State licensing board actions to determine if an individual practitioner, such as a physician or nonphysician practitioner continues to meet State licensing requirements. (HHS/CMS Final Rules (1/24/2011) pp.29-30). According to CMS: We issued guidance on June 12, 2008, to State Medicaid Directors recommending that they check their enrolled providers for exclusions on a monthly basis. and We followed up that guidance on January 16, 2009, with guidance to State Medicaid Directors recommending that they require their enrolled providers to check the providers' employees and contractors for exclusions on a monthly basis. Those letters are available at: Many States made our recommendations their policy. Section does not mandate that States require their providers to check the LEIE and EPLS on a monthly basis to determine whether the providers' employees and contractors have been excluded. We do, however, recommend that States consider making this a requirement for all providers and contractors, including managed care contractors in their Medicaid programs and CHIP. (HHS/CMS Final Rules (1/24/2011) p. 158). The CMS also advises States should report terminations on a monthly basis in order to assist other States and the Medicare program in protecting themselves from providers who pose an increased risk to government health care programs. (HHS/CMS Final Rules (1/24/2011) p. 352). Effect on License Monitoring, Sanctions and Exclusions Screening: Licenses - CMS requires that contractors conduct monthly reviews of State licensing board actions to determine if an individual practitioner continues to meet State licensing requirements. Sanctions - CMS requires that contractors conduct monthly reviews of State licensing board actions to determine if an individual practitioner continues to meet State licensing requirements. Exclusions - (PPACA) expands the definition of Exclusions to include additional crimes and civil actions such as failure to pay student loans and convictions involving controlled substances. As of January 1, 2011, employers must conduct a search of ALL State Medicaid actions to determine if a licensee has been excluded or

3 terminated from any other State Medicaid program. As of March 25, 2011, the PPACA recommends with guidance monthly screening for exclusions at the State and Federal level for those participating in Medicaid programs and CHIP. CMS Civil Monetary Penalties (CMP s): Expanded The PPACA expands the availability of CMPs by CMS to be used against providers under (Sections 6402 and 6408 of PPACA CMS Provisions). The following activities were identified for the assessment of additional CMPs: Knowingly retaining an overpayment and not reporting and returning such overpayment. Failing to grant timely access to the OIG for audits, investigations, or other statutory function (penalty up to $15,000 per day). Knowingly making, using, or causing to be made or used a false record or statement material to a false or fraudulent claim for payment under a Federal health care program (penalty up to $50,000 for each claim). Knowingly making a false statement or misrepresentation on any Federal health care program application, bid or contract (penalty up to $50,000 for each claim). Ordering or prescribing a service during a period in which the person was excluded from a Federal health care program (penalty up to $50,000 for each order or prescription) Suspension of Payments Pending Investigation: Section 6402(h) PPACA CMS Provisions provides that Medicare and Medicaid payments to a provider may be suspended pending investigation of a credible allegation of fraud against the provider, unless HHS determines that there is good cause not to suspend such payments. The provision further directs the Secretary of HHS to consult with the OIG in determining whether there is a credible allegation of fraud against the provider.

4 All In One Solution Provided by Shield Screening Shield Screening s Medical Monitoring program exceeds all Federal and State monitoring compliance regulations and guidelines for pre-employment screening and ongoing mandated monitoring. Monthly Monitoring of all new hire and current employees including volunteers: 1.) Upon hire and every month thereafter all employees (full and part time), consultants, governing body member or FDR and volunteers undergo monitoring. a. Monitoring includes all exclusion databases (OIG, DHHS, EPLS, GSA, LEIE, Excluded Entities, et al) while also giving access to state and federal infractions and disciplinary boards, licensing boards, credentialing boards etc. b. Searches are automated in nature and are both verified and adjudicated by expert researchers with at least five years experience in the field. 2.) All business or volunteer entities that you are contracted with may also undergo screening. These entities are then checked against monthly alerts and updates for entities added to all entity exclusion lists that are newly provided each month. a. Entities undergo screening upon agreement to do business and are screened against LEIE and EPLS alert and exclusion lists that are supplement files released each month. b. Searches are automated in nature and verified and adjudicated by expert researchers with at least five years experience in the field. What Shield Medical Monitoring Includes: Shield Medical Monitoring identifies any wrong actions of individuals and entities in the health care field.

5 This includes information on disciplinary actions ranging from exclusions and debarments to letters of reprimand and probation. Our search meets and exceeds all federal requirements and includes more than 800 sources in 50 states. Search sources include but are not limited to: General Services Administration (GSA) Office of the Inspector General (OIG) Food and Drug Administration (FDA) Drug Enforcement Administration (DEA) TriCare Other state and federal agencies More than 800 sources in 50 states Please feel free to contact us with any questions regarding our Medical Monitoring Programs or compliance. For More Information Please Contact: Agents for: