Medicare, Medicaid and CHIP Programs Integrity
- Provider Screening and Other Enrollment Requirements. HHS must establish pre-screening and other fraud control requirements for providers and suppliers enrolling in Medicare, Medicaid and CHIP. Adds new authority for HHS and states to control enrollment and implement compliance programs and to disclose the identity of terminated providers and suppliers. Gives HHS the authority to adjust payments to providers and suppliers to satisfy any past-due obligations. Effective 9/19/10. (PPACA §§ 6401, 10603)
- 90-Day DME Payment Hold. HHS must hold Medicare payment of a durable medical equipment (DME) supplier’s claims for 90 days if there is a significant risk of fraudulent activity among DME suppliers in a geographic area or within a category of DME. Effective 1/1/11. (HCERA § 1304)
- Enhanced Program Integrity Funding Provisions. Authorizes substantial new funding for enhanced Medicare and Medicaid Program integrity operations FYs 2011-2020. Effective date of enactment. Adds $250 million to the HHS Medicare Health Care Fraud and Abuse Account in Treasury over the period FY 2011 through FY 2016. (PPACA § 6402; HCERA § 1303)
- Eliminating Duplication between Data Banks. HHS shall stop operating the Healthcare Integrity and Protection Data Bank and shall transfer all information to the National Practitioner Data Bank. HHS shall issue regulations to maintain a program to collect and furnish information about certain final adverse fraud-related penalty and sanction actions to the National Practitioner Data Bank. States shall create and maintain systems for reporting licensing, certification and other adverse actions to the Data Bank. Adverse action information in the Data Bank shall be available for a disclosure fee. No person or entity shall be civilly liable for the reporting or disclosure of this information. Effective on date of enactment. (PPACA § 6403)
- Maximum Period for Submission of Medicare Claims. Maximum time for Medicare providers to submit claims reduced to not more than 12 months. Effective for services furnished on or after 1/1/10 (with claims for services provided before 1/1/10 to be submitted by 12/31/10). (PPACA § 6404)
- Physicians Ordering DME or HH Services. Physicians who order home health or DME are required to be enrolled in Medicare. HHS may extend requirement to other categories of items or services. Effective 7/1/10. (PPACA §§ 6405, 10604)
- Documentation on Referrals to Programs at High Risk of Waste and Abuse. Physicians ordering DME and home health services must produce supporting documentation upon request of HHS or face disenrollment from Medicare for up to a year. Effective 1/1/10. (PPACA § 6406)
- Face-to-Face Encounter Prior to Ordering Home Health / DME. Physicians or covered nurse practitioner specialists must document that there has been a face-to-face encounter with a Medicare eligible patient prior to ordering DME or home health services. HHS may extend the face-to-face encounter requirement to other Medicare covered items and services. Effective 1/1/10. (PPACA §§ 6407, 10605)
- Medicare Self-Referral Disclosure Protocol. Directs HHS to develop, not later than 9/23/10, a self-referral disclosure protocol (SRDP) for violations of the physician self-referral prohibition (Stark) and permits HHS to reduce a provider’s penalties for the use of such SRDP. (PPACA §6409)
- Adjustments to DME Competitive Bidding Program
- Increases the expansion of phase 2 DME competitive bidding areas from 70 to 91 new metropolitan areas. (PPACA § 6410(a))
- HHS shall competitively bid DME covered by Medicare or use competitive bid prices in paying for DME in all remaining areas. Effective 1/1/16. (PPACA § 6410(b))
- Expansion of Recovery Audit Contractor Program. Expands federal Recovery Audit Contractor (RAC) program to Medicaid and Medicare Parts C and D. Effective 12/31/10. (PPACA § 6411)
- Oversight of Community Mental Health Centers. Redefines the term “community mental health center” (for purposes of Medicare coverage of partial hospitalization services) to require that at least 40% of services must be furnished to individuals not eligible for Medicare, and specifies that a program of partial hospitalization services is one that does not offer services in the patient’s home or in an inpatient or residential setting. Effective 4/1/11. (HCERA §1301)
- Contractor Random Prepayment Review. Repeals current statutory limits on contractor use of random and non-random prepayment review (i.e., a contractor’s demand for records and documentation does not have to be related to a specific claim). (HCERA § 1302).
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Additional Program Integrity Provisions
- Clarifying Definition. Expands the definition of “federal health care offense” to include ERISA-related convictions and other criminal violations by benefit plan personnel. Effective upon enactment. (PPACA § 6602)
- Model Uniform Report Form. Directs NAIC to develop a model fraud and abuse reporting form and submit reporting standards recommendations to HHS. Effective upon enactment. (PPACA § 6603)
- Evidentiary Privilege and Confidential Communications. Permits DOL to establish, by regulation, a confidentiality of communications and evidentiary privilege between DOL, DOT, DOJ, HHS and a state AG or insurance agency, and the NAIC related to any investigation, audit, examination or inquiry conducted by these agencies. Effective upon enactment. (PPACA § 6607)
- Fraud Enforcement. Directs the development of higher penalties in the federal sentencing guidelines for federal health care crimes. Grants administrative subpoena power for health care records related to HIPAA and institutionalized person civil rights cases. Effective upon enactment. (PPACA § 10606)
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