Medicaid Providers Beware: Here Comes the Pre-Enrollment Site Visits!

In the April 2013 Medicaid Bulletin, Department of Health and Human Services (DHHS) announced that Public Consulting Group (PCG) is beginning to schedule pre-enrollment site visits.

Why? Why? Why more  harassment and audits??! I mean, come one, how many audits can we endure?  Pre-payment reviews, Tentative Notices of Overpayment…now this?

What is a pre-enrollment site visit?  Essentially a pre-enrollment site visit is a mini-Medicaid audit to determine that all licenses, staff requirements, and other administrative items are in compliance with state and federal law. But these mini-audits can get (for lack of better word) non-mini. As in these audits can be huge and create potentially dire consequences to the providers.  Each individual provider’s audit’s procedure will depend on whether the provider is deemed “low,” “moderate” or “high” risk.

As defined by N.C. Gen. Stat., LOW RISK are the following types of providers:

  1. Ambulatory surgical centers.
  2. End-stage renal disease facilities.
  1. Federally qualified health centers.
  2. Health programs operated by an Indian Health Program (as defined in section 4(12) of the Indian Health Care Improvement Act) or an urban Indian organization (as defined in section 4(29) of the Indian Health Care Improvement Act) that receives funding from the Indian Health Service pursuant to Title V of the Indian Health Care Improvement Act.
  1. Histocompatibility laboratories.
  2. Hospitals, including critical access hospitals, Department of Veterans Affairs Hospitals, and other State or federally owned hospital facilities.
  1. Local Education Agencies.
  2. Mammography screening centers.
  3. Mass immunization roster billers.
  4. Nursing facilities, including Intermediate Care Facilities for the Mentally Retarded.
  1. Organ procurement organizations.
  2. Physician or nonphysician practitioners (including nurse practitioners, CRNAs, physician assistants, physician extenders, occupational therapists, speech/language pathologists, chiropractors, and audiologists), optometrists, and medical groups or clinics.
  3. Radiation therapy centers
  4. Rural health clinics
  5. Hearing aid dealers:

MODERATE RISK

1. Ambulance services.

2. Comprehensive outpatient rehabilitation facilities.

3. Critical Access Behavioral Health Agencies.

4. Dentists and orthodontists.

5. Hospice organizations.

6. Independent clinical laboratories.

7.  Independent diagnostic testing facilities.

8.  Pharmacy Services.

9.  Physical therapists enrolling as individuals or as group practices.

10.  Revalidating adult care homes delivering Medicaid-reimbursed services.

11.  Revalidating agencies providing durable medical equipment, including, but not limited to, orthotics and prosthetics.

12.  Revalidating agencies providing home or community-based services pursuant to waivers authorized by the federal Centers for Medicare and Medicaid Services under 42 U.S.C. § 1396n(c).

13.  Revalidating agencies providing private duty nursing, home health, personal care services or in-home care services, or home infusion.

HIGH RISK:

1.  Prospective (newly enrolling) adult care homes delivering Medicaid-reimbursed services.

2.  Agencies providing behavioral health services, excluding Critical Access Behavioral Health Agencies

3.  Directly enrolled outpatient behavioral health services providers.

4.  Prospective (newly enrolling) agencies providing durable medical equipment, including, but not limited to, orthotics and prosthetics.

5.  Agencies providing HIV case management.

6.  Prospective (newly enrolling) agencies providing home or community-based services pursuant to waivers authorized by the federal Centers for Medicare and Medicaid Services under 42 U.S.C. § 1396n(c).

7.  Prospective (newly enrolling) agencies providing personal care services or in-home care services.

8.  Prospective (newly enrolling) agencies providing private duty nursing, home health, or home infusion.

9.  Providers against whom the Department has imposed a payment suspension based upon a credible allegation of fraud in accordance with 42 C.F.R. § 455.23 within the previous 12-month period. The Department shall return the provider to its original risk category not later than 12 months after the cessation of the payment suspension.

10.  Providers that were excluded, or whose owners, operators, or managing employees were excluded, by the U.S. Department of Health and Human Services Office of Inspector General or another state’s Medicaid program within the previous 10 years. 

11.  Providers who have incurred a Medicaid or Health Choice final overpayment, assessment, or fine to the Department in excess of twenty percent (20%) of the provider’s payments received from Medicaid and Health Choice in the previous 12-month period. The Department shall return the provider to its original risk category not later than 12 months after the completion of the provider’s repayment of the final overpayment, assessment, or fine.

12.  Providers whose owners, operators, or managing employees were convicted of a disqualifying offense pursuant to G.S. 108C-4 but were granted an exemption by the Department within the previous 10 years.

Ok, how does the audit differ depending on whether the provider is classified as low, moderate, or high risk?

42 CFR  455.432 describes the following:

FOR LOW RISK

(1) Verify that a provider meets any applicable Federal regulations, or State requirements for the provider type prior to making an enrollment determination.

(2) Conduct license verifications, including State licensure verifications in States other than where the provider is enrolling, in accordance with § 455.412.

(3) Conduct database checks on a pre- and post-enrollment basis to ensure that providers continue to meet the enrollment criteria for their provider type, in accordance with § 455.436.

FOR MODERATE RISK

(1) Perform the “limited” screening requirements described in paragraph (a) of this section.

(2) Conduct on-site visits in accordance with § 455.432.

FOR HIGH RISK

(1) Perform the “limited” and “moderate” screening requirements described in paragraphs (a) and (b) of this section.

(2)(i) Conduct a criminal background check; and

(ii) Require the submission of a set of fingerprints in accordance with § 455.434.

It is important to  note that providers are automatically high risk if the provider is on prepayment review or received  a Tentative Notice of Overpayment.  Even more reason to fight prepayment  reviews and Tentative Notices of Overpayment.

About kemanuel

Medicare and Medicaid Regulatory Compliance Litigator

Posted on April 8, 2013, in DHHS, Division of Medical Assistance, Federal Law, Harassment, Health Care Providers and Services, Legal Analysis, Legislation, MCO, Medicaid, Medicaid Audits, North Carolina, Tentative Notices of Overpayment, Termination of Medicaid Contract and tagged , , , , , . Bookmark the permalink. Leave a comment.

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