Surgery centers, physicians and group practices are among providers that would be considered "limited" fraud risk providers to government insurances programs, according CMS proposed rule CMS-6028-P.
As a limited-risk entity, these providers would undergo the following screening procedures:
(1) verification that a provider or supplier meets any applicable Federal regulations, or State requirements for the provider or supplier type prior to making an enrollment determination; and
(2) verification that a provider or supplier meets applicable licensure requirements; and (3) database checks on a pre- and post-enrollment basis to ensure that providers and suppliers continue to meet the enrollment criteria for their provider/supplier type.
Also considered limited risk are providers or suppliers publicly traded on NYSE or NASDAQ.
"Moderate"-risk entities would include community mental health centers, comprehensive outpatient rehabilitation facilities and independent diagnostic testing facilities (except those that are publicly traded). They would undergo the same screening procedures as limited-risk entities and will undergo unannounced pre- and/or post-enrollment site visits by Medicare contractors.
"High"-risk entities would include prospective (newly enrolling) home health agencies and suppliers of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) (except those that are publicly traded). In addition to the screening tools applicable to limited- and moderate-risk entities, Medicare contractors would use the following screening tools in the enrollment process for high-risk entities:
(1) criminal background check; and
(2) submission of fingerprints using the FD-258 standard fingerprint card.
Other proposed screening tools include:
- $500 application fee;
- granting CMS the authority to impose a moratorium on enrollment of new Medicare providers and suppliers in six-month increments in situations when CMS identifies a trend that appears to be associated with a high risk of fraud, waste or abuse; and
- requirement of states to terminate enrollment when CMS terminates enrollment.
View the CMS proposed fraud rule (pdf).