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Provider Enrollment and the Affordable Care Act
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  1. Provider Enrollmentand the Affordable Care Act HP Provider Relations February 2012

  2. Agenda • Session Objectives • Provider Enrollment Web Pages • Affordable Care Act (ACA) Impact • Disclosed Individuals • Profile Updates • Risk Levels • Provider Screening • Background Checks • Associated Fees

  3. Objectives • Know the screening tasks that apply to your provider type • Understand the impact of your assigned risk level • Know if your provider type is required to pay an enrollment fee • Be aware of the database checks that apply to all enrollments

  4. On the Web Indianamedicaid.com

  5. Affordable Care Act

  6. To enroll, select your provider type To enroll, select your provider type

  7. Choose an update form

  8. Define What is the ACA?

  9. Affordable Care Act Impact on Provider Enrollment Centers for Medicare & Medicaid Services (CMS) Rule 6028-FC of the ACA provides procedures under which screening activities are performed for providers in Medicare and state Medicaid programs. Screening activities place heightened emphasis on program integrity designed to reduce fraud, waste, and abuse in the Medicare and Medicaid programs.

  10. Affordable Care Act Impact on Provider Enrollment On January 1, 2012, the Indiana Health Coverage Programs (IHCP) adopted and enacted new provider enrollment and screening requirements mandated by the ACA. Screening and pre-enrollment procedures are applicable to: • New providers enrolling for the first time • Existing providers adding new service locations; and, • Existing providers revalidating their enrollment.

  11. Affordable Care Act Impact on Provider Enrollment All IHCP providers must revalidate their enrollment at intervals not to exceed every five years A more frequent revalidation requirement not to exceed every three-years applies to Durable Medical Equipment – Prosthetics, Orthotics and Supply (DMEPOS) providers • Durable medical equipment (DME) providers • Pharmacy providers with DME or home medical equipment (HME) specialty enrollments

  12. Affordable Care Act Revalidation versus Recertification Revalidation • Required for all currently enrolled providers at intervals of three or five years • Involves completing a new enrollment application • Requires performance of all risk-appropriate screening activities • May require payment of the application fee

  13. Affordable Care Act Revalidation versus Recertification Recertification • Required for currently enrolled out-of-state providers of certain specialties • Hospital – Upon renewal of license or Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) certification • Some Extended Care Facilities – Annual submission of a newly signed Provider Agreement • Ambulance – Upon issuance of a renewed Emergency Medical Service (EMS) certificate or EMS Air Ambulance certificate • Transportation – Upon issuance of a renewed Motor Carrier Services (MCS) certificate/operating authority or Livery license and insurance policy • Requires completion of the IHCP Provider Recertification Form • Does not require completion of a new enrollment application • Does not require completion of screening activities • Does not require payment of the application fee

  14. Define Disclosed Individuals

  15. Disclosed Individuals Paper Enrollment Application Schedule C, sections C.1 through C.3 of the IHCP Provider Enrollment Application collects the names of disclosed individuals. Disclosure information refers to the identification of: • Business owners • Officers • Managers • Members of the Board of Directors • Managers responsible for day-to-day operations The ACA mandates background checks for the owners of a provider entity

  16. Disclosed Individuals Web interChange Disclosure information is also collected via the Provider Profile feature of Web interChange. • Applies to providers assigned to the limited risk category only A field has been added to Web interChange Provider Profile to capture, store, and display the date of birth for all disclosed individuals. Web interChange requires the addition of the date of birth for new entries and updates to existing entries for disclosed individuals and rendering providers.

  17. Disclosure Information

  18. Profile Updates

  19. Profile Updates • The following Web interChange updates to a provider’s profile will not be allowed for providers assigned to the High and Moderate risk categories: • Service Location address change • Unannounced, unscheduled site visits will be conducted before the address change is approved • Addition and removal of names from the disclosure information • Disclosed individuals are subject to screening activities before changes are approved Note: These profile updates must be performed using the paper forms

  20. Profile Updates Paper maintenance forms • Providers may continue to use paper update forms to perform maintenance to their profile. • Modifications have been made to the following maintenance forms: • IHCP Name Address Maintenance Form • IHCP Claim Certification Statement for Signature on File Addendum • IHCP CLIA Certification Maintenance Form • IHCP Delegated Administrator Addendum • IHCP Electronic Funds Transfer Addendum • IHCP Medicare Number Maintenance Form • IHCP Recertification Form • IHCP Disenrollment Form • IHCP Specialty Maintenance Form • IHCP Tax Identification Maintenance Form • IHCP Psychiatric Hospital Bed Addendum • IHCP PRTF Attestation Letter Information Modifications include the addition of Social Security Number and date of birth fields, a fee payment form and background/fingerprint check form.

  21. Identify Risk Levels

  22. Risk Levels • All provider types and specialties are assigned to one of the following risk levels. Waiver providers are assigned risk levels at the subspecialty level. • High • Moderate • Limited • Providers are subject to screening tasks based on their assigned risk level • The risk level categorization is established by the CMS, based on an assessment of potential for fraud, waste, and abuse for each provider type/specialty • The Provider Type Application Fee and Risk Assignment Matrix (for Non-Waiver and Waiver providers) provides a full list of provider types and their assigned risk level. NOTE: Review this document before revalidating to review current requirements

  23. Risk Levels Risk level – High • Newly enrolling home health agency (HHA) • Newly enrolling hearing aid dealer • Newly enrolling pharmacy with DME or HME specialty • Newly enrolling DME supplier • Newly enrolling nonemergency transportation provider • Newly enrolling waiver specialized medical equipment and supplies provider • Newly enrolling waiver attendant care providers Risk Category - High

  24. Risk Levels Risk level – Moderate • Rehabilitation facility with comprehensive outpatient rehab facility specialty • Revalidating home health agency • Hospice • Clinic with therapy clinic specialty • Mental health provider with Community Mental Health Center (CMHC) specialty • Physical therapist • Revalidating hearing aid dealer • Revalidating pharmacy with DME/HME specialty • Revalidating DME supplier • Ambulance and air ambulance provider • Revalidating nonemergency transportation provider Risk Category - Moderate

  25. Risk Levels Risk level – Moderate • Independent lab, mobile lab, independent diagnostic testing facility (IDTF), mobile IDTF • Mobile x-ray clinic • Revalidating waiver provider offering specialized medical equipment and supplies, or waiver physical therapy provider • Revalidating waiver attendant care provider • New waiver consultative clinical and therapeutic service provider • Newly enrolling waiver flex funds provider • Waiver Community Alternatives to Psychiatric Residential Treatment Facilities (CA-PRTF) habilitation providers • Waiver wraparound facilitation care coordinators • Waiver wraparound technicians Risk Category - Moderate

  26. Risk Levels Risk level – Limited • Hospital • Ambulatory surgical center (ASC) • Extended care facility • Federally Qualified Health Center (FQHC) • Rural health clinic (RHC) • Advanced practice nurse (APN) • Pharmacy • Dentist • End-stage renal disease clinic (ESRD) • Physician • Clinic • Birthing center Risk Category - Limited

  27. Risk Levels Risk level – Limited • Physician assistant (not currently enrolled) • Outpatient mental health clinic • health service provider in psychology (HSPP) • School corporation • Public health agency • Podiatrist • Chiropractor • Occupational therapist • Speech/hearing therapist • Optometrist • Optician • Audiologist Risk Category - Limited

  28. Risk Levels Risk level – Limited • Case manager • Family member transportation provider • Free-standing X-ray clinic • All waiver providers not listed as High or Moderate risk • Extended care facility • Rehabilitation facility • Medical clinic • Family planning clinic • Nurse practitioner clinic • Dental clinic Risk Category - Limited

  29. Screen Due Diligence

  30. Provider Screening Screening tasks Prior to completing enrollment processing, providers are subject to the screening tasks based on their risk category. High risk category : • Unscheduled, unannounced site visits • Site visits are conducted prior to and after an approved enrollment • Fingerprinting of disclosed individuals with a 5% or more ownership interest • Criminal background check for disclosed individuals with a 5% or more ownership interest • Validation of disclosed individuals with the Office of the Inspector General (OIG) Excluded Parties List System (EPLS), the Excluded Individuals database, and the Social Security Death Master List • License verification • Proof of Medicare enrollment, if Medicare-enrolled

  31. Provider Screening Screening tasks Moderate risk category • Unscheduled, unannounced site visits • Site visits are conducted prior to and after an approved enrollment • Validation of disclosed individuals with the OIG Excluded Parties List System, the Excluded Individuals database, and the Social Security Death Master List • License verification • Proof of Medicare enrollment, if Medicare-enrolled Limited risk category : • Validation of disclosed individuals with the OIG Excluded Parties List System, the Excluded Individuals database, and the Social Security Death Master List • License verification • Proof of Medicare enrollment, if Medicare-enrolled All screening tasks for all risk categories are performed for each service location individually

  32. Provider Screening Database checks The Excluded Parties List System identifies individuals that are debarred, suspended, excluded, or disqualified from receiving federal contracts, subcontracts, financial, and nonfinancial assistance and benefits. The OIG Exclusion List identifies individuals that are excluded from participation in Medicare, Medicaid, and Title XX programs. The Social Security Death Master List is the national repository to validate that an individual is deceased. Provider bulletin BT200934 reminds providers of their responsibility to screen disclosed individuals and employees prior to hiring and periodically thereafter.

  33. Provider Screening Database checks Providers that were terminated from Medicare or another state’s Medicaid program are reviewed using the Medicaid and CHIP State Information Sharing System (MCSIS) database. • These providers are not eligible to participate in the IHCP. Providers that were sanctioned by the OIG are not eligible to enroll in the IHCP. The names of disclosed individuals for currently enrolled providers are validated on the MCSIS, EPLS and OIG databases on a monthly basis.

  34. Background Check

  35. Background Check • Disclosed individuals with a 5% or more ownership in a “high risk” provider entity are required to undergo a background investigation and fingerprinting. • The IHCP utilizes a third party vendor to provide the following services: • Fingerprinting • Background Investigation

  36. Background Check Process Disclosed individuals access the links on indianamedicaid.com to make arrangements for fingerprinting. Disclosed individuals will make an appointment at a nearby collection site using the links on indianamedicaid.com . Fingerprints are sent electronically to the Federal Bureau of Investigation (FBI) for processing. The FBI will return the Criminal History Reports to the IHCP. Each disclosed individual requiring fingerprinting will pay a separate fee to the fingerprint collection site.

  37. Describe Application Fees

  38. Fees • The application fee for 2012 is $523. • A $523 application fee will be collected only from Institutional providers (as defined by CMS) that have not paid the application fee to Medicare, or who have not paid the fee in another state Medicaid program. • Out of state providers that enroll or revalidate with the IHCP must provide proof of payment of the application fee, if paid to their state’s Medicaid program. • The application fee applies to newly enrolling and revalidating providers, and existing providers adding a new service location. • The application fee amount may be changed annually.

  39. Fees • Application fee (based on provider type and specialty) • Institutional providers will pay a fee to enroll in the Medicare or Medicaid programs. • Dually enrolled providers will pay the fee only to Medicare. • Medicaid-only providers will pay the fee to Medicaid. • Each service location must pay the fee upon enrolling and revalidating . • Review the Provider Type and Specialty Matrix at http://provider.indianamedicaid.com/media/27745/matrix.pdf to determine if an application fee is required for your provider type. • Payment methods include: • Check • Money order • Credit/debit card using HP Convenience Pay • Electronic check including Automated Clearing House (ACH) and electronic funds transfer (EFT)

  40. Fees • The IHCP will use HP Convenience Pay to process credit/debit card payments of the application fee. • The Convenience Pay Services Client Access Portal provides authorized users with online, real-time access to ACH/EFT self-service capabilities. • HP Convenience Pay can be accessed via indianamedicaid.com or https://www.paybill.com/ClientAccessPortal/Login.aspx.

  41. Find Help Resources Available

  42. Helpful Tools Avenues of resolution Provider Enrollment page at indianamedicaid.com HP Convenience Pay https://www.paybill.com/ClientAccessPortal/Login.aspx IHCP Provider Manual, Chapter 4 (Web, CD-ROM, or paper) Provider Bulletin BT201151 Provider Enrollment Phone Line • 1-877-707-5750 Provider field consultant • provider.indianamedicaid.com/contact-us/provider-relations-field-consultants.aspx

  43. Q&A