Transcript Provider Enrollment and the Affordable Care Act

Provider Enrollment
and the Affordable Care Act
HP Provider Relations
February 2012
Agenda
– Session Objectives
– Provider Enrollment Web Pages
– Affordable Care Act (ACA) Impact
– Disclosed Individuals
– Profile Updates
– Risk Levels
– Provider Screening
– Background Checks
– Associated Fees
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Provider Enrollment and the ACA
February 2012
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
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Provider Enrollment and the ACA
February 2012
On the Web
Indianamedicaid.com
Affordable Care Act
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Provider Enrollment and the ACA
February 2012
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Footer Goes Here
Toenroll,
enroll,
To
select
select
your
your
provider
provider
type
type
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Choose
an
update
form
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Define
What is the ACA?
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.
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Provider Enrollment and the ACA
February 2012
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:
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New providers enrolling for the first time
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Existing providers adding new service locations; and,
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Existing providers revalidating their enrollment.
Provider Enrollment and the ACA
February 2012
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 threeyears applies to Durable Medical Equipment – Prosthetics, Orthotics
and Supply (DMEPOS) providers
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Durable medical equipment (DME) providers
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Pharmacy providers with DME or home medical equipment (HME) specialty
enrollments
Provider Enrollment and the ACA
February 2012
Affordable Care Act
Revalidation versus Recertification
– Revalidation
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Required for all currently enrolled providers at intervals of three or five years
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Involves completing a new enrollment application
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Requires performance of all risk-appropriate screening activities
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May require payment of the application fee
Provider Enrollment and the ACA
February 2012
Affordable Care Act
Revalidation versus Recertification
– Recertification
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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
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Requires completion of the IHCP Provider Recertification Form
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Does not require completion of a new enrollment application
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Does not require completion of screening activities
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Does not require payment of the application fee
Provider Enrollment and the ACA
February 2012
Define
Disclosed Individuals
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:
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Business owners
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Officers
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Managers
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Members of the Board of Directors
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Managers responsible for day-to-day operations
– The ACA mandates background checks for the owners of a provider
entity
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Provider Enrollment and the ACA
February 2012
Disclosed Individuals
Web interChange
– Disclosure information is also collected via the Provider Profile feature
of Web interChange.
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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.
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Provider Enrollment and the ACA
February 2012
Disclosure Information
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Provider Enrollment and the ACA
February 2012
Profile Updates
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:
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Service Location address change
− Unannounced, unscheduled site visits will be conducted before the address change is approved
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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
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Provider Enrollment and the ACA
February 2012
Profile Updates
Paper maintenance forms
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Providers may continue to use paper update forms to perform maintenance to their
profile.
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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
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Provider Enrollment and the ACA
February 2012
Modifications include the addition
of Social Security Number and
date of birth fields, a fee payment
form and background/fingerprint
check form.
Identify
Risk Levels
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.
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High
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Moderate
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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 NonWaiver 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
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Provider Enrollment and the ACA
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Risk Levels
Risk level – High
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Risk
Category High
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Provider Enrollment and the ACA
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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 Levels
Risk level – Moderate
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Risk
Category Moderate
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Provider Enrollment and the ACA
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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 Levels
Risk level – Moderate
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Independent lab, mobile lab, independent
diagnostic testing facility (IDTF), mobile IDTF
• Mobile x-ray clinic
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Risk
Category Moderate
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Provider Enrollment and the ACA
Revalidating waiver provider offering
specialized medical equipment and supplies,
or waiver physical therapy provider
• Revalidating waiver attendant care provider
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New waiver consultative clinical and
therapeutic service provider
• Newly enrolling waiver flex funds provider
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Waiver Community Alternatives to Psychiatric
Residential Treatment Facilities (CA-PRTF)
habilitation providers
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Waiver wraparound facilitation care
coordinators
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Waiver wraparound technicians
February 2012
Risk Levels
Risk level – Limited
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Risk
Category Limited
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Provider Enrollment and the ACA
February 2012
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 Levels
Risk level – Limited
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Risk
Category Limited
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Provider Enrollment and the ACA
February 2012
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 Levels
Risk level – Limited
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Risk
Category Limited
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Provider Enrollment and the ACA
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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
Screen
Due Diligence
Provider Screening
Screening tasks
– Prior to completing enrollment processing, providers are subject to the
screening tasks based on their risk category.
– High risk category :
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Unscheduled, unannounced site visits
− Site visits are conducted prior to and after an approved enrollment
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Fingerprinting of disclosed individuals with a 5% or more ownership interest
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Criminal background check for disclosed individuals with a 5% or more ownership
interest
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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
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License verification
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Proof of Medicare enrollment, if Medicare-enrolled
Provider Enrollment and the ACA
February 2012
Provider Screening
Screening tasks
– Moderate risk category
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Unscheduled, unannounced site visits
− Site visits are conducted prior to and after an approved enrollment
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Validation of disclosed individuals with the OIG Excluded Parties List System, the
Excluded Individuals database, and the Social Security Death Master List
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License verification
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Proof of Medicare enrollment, if Medicare-enrolled
– Limited risk category :
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Validation of disclosed individuals with the OIG Excluded Parties List System, the
Excluded Individuals database, and the Social Security Death Master List
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License verification
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Proof of Medicare enrollment, if Medicare-enrolled
– All screening tasks for all risk categories are performed for each
service location individually
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Provider Enrollment and the ACA
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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.
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Provider Enrollment and the ACA
February 2012
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.
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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.
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Provider Enrollment and the ACA
February 2012
Background Check
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:
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Fingerprinting
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Background Investigation
Provider Enrollment and the ACA
February 2012
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.
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Provider Enrollment and the ACA
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Describe
Application Fees
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.
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Provider Enrollment and the ACA
February 2012
Fees
– Application fee (based on provider type and specialty)
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Institutional providers will pay a fee to enroll in the Medicare or Medicaid programs.
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Dually enrolled providers will pay the fee only to Medicare.
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Medicaid-only providers will pay the fee to Medicaid.
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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)
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Provider Enrollment and the ACA
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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.
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Provider Enrollment and the ACA
February 2012
Find Help
Resources Available
Helpful Tools
Avenues of resolution
– Provider Enrollment page at
indianamedicaid.com
– HP Convenience Pay
https://www.paybill.com/ClientAccess
Portal/Login.aspx
– IHCP Provider Manual, Chapter 4
(Web, CD-ROM, or paper)
– Provider Bulletin BT201151
– Provider Enrollment Phone Line
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1-877-707-5750
– Provider field consultant
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provider.indianamedicaid.com/contactus/provider-relations-field-consultants.aspx
Provider Enrollment and the ACA
February 2012
Q&A