Under the new law, CMS will expand the current Medicare provider enrollment process to include additional methods of screening practitioners enrolling in the Medicare program. CMS is required to conduct licensure checks. These checks may be conducted across multiple states. Additionally, CMS is permitted to conduct criminal background checks, fingerprinting, unscheduled and unannounced site visits, and other mechanisms that can be used to screen potential providers of Medicare services for fraudulent or otherwise criminal behavior. While originally, the law also required the collection of an application fee for both individual and institutional providers, such as hospitals or skilled nursing facilities, the fee is no longer required for individual providers.
By law, the new screening requirements will apply to newly enrolling practitioners beginning in 2011 and to currently enrolled practitioners making changes to their enrollment application beginning in 2012. CMS is to include these new requirements as part of the revalidation process in about six months.
Additionally, the PPACA permits CMS to require certain sectors or categories of enrolled providers to establish compliance programs as a condition of Medicare enrollment. CMS will be required to determine the core elements of such compliance program if it chooses to require them. CMS will also be allowed to establish temporary moratoria on the enrollment of different provider types if it determines that it is necessary to combat fraud and abuse.
The law also dictates that these new measures be included as part of provider enrollment in state Medicaid programs. In addition to the requirements detailed above, state Medicaid programs must also require that ordering and referring physicians be enrolled in their program and that the National Provider Identifier (NPI) of ordering or referring physicians be included on claims.
The College opposes requirements that make it more costly and burdensome for cardiovascular professionals to furnish services to patients and will work with CMS to ensure that these requirements are implemented in a manner that minimizes the burdens and costs for physician practices. CMS must issue regulations on these requirements, and the ACC will work closely with the Agency on this issue.
Previously, practitioners had three calendar years from the date of service to file claims. The PPACA requires that all claims for services be filed within one calendar year after the date of service, unless an exception is made by CMS. For services furnished before Jan. 1, 2010 where claims have not yet been filed, those claims must be filed no later than Dec. 31, 2010.