Existing Home Health Agencies Considered a Moderate Risk

Existing Home Health Agencies are Considered to be a Moderate Risk

(October 5, 2010): Existing home health agencies are considered to be a Moderate Risk for screening purposes. Late last month, the Centers for Medicare & Medicaid Services (CMS) published a Proposed Rule entitled “Medicare, Medicaid, and Children’s Health Insurance Programs; Additional Screening Requirements, Application Fees, Temporary Enrollment Moratoria, Payment Suspensions and Compliance.” As set out in the Proposed Rule, the Health Care Reform Act passed last March:

“. . . makes a number of changes to the Medicare and Medicaid programs and CHIP that enhance the provider and supplier enrollment process to improve the integrity of the programs to reduce fraud, waste, and abuse in the programs.”

Among these various changes mandated by the legislation, the Secretary, HHS, is required to determine the level of screening applicable to providers and suppliers according to the risk of fraud, waste, and abuse the Secretary determines is posed by particular categories of providers and suppliers. As set out in the Proposed Rule, CMS intends to categorize health care providers and suppliers by the “Level of Risk” generally associated with that type of provider or supplier. Three levels of risk have been identified, “Limited,” “Moderate,” and “High.” The types of screening tools to which a provider will be subjected vary depending on the level of risk assigned to a specific type of provider or supplier by CMS. The types of screening tools to be used at each level of risk include the following:

Category of Risk and Required Screening for Medicare Physicians, Non-Physician Practitioners, Providers, and Suppliers

Type of Screening Required Limited Moderate High
Verification of any provider/supplier-specific requirements established by Medicare X X X
Conduct license verifications, (may include licensure checks across States) X X X
Database Checks (to verify Social Security Number (SSN), the National Provider Identifier (NPI), the National Practitioner Data Bank (NPDB) licensure, OIG exclusion, taxpayer identification number, tax delinquency, death of individual practitioner, owner, authorized official, delegated official, or supervising physician) X X X
Unscheduled or Unannounced Site Visits X X
Criminal Background Check X
Fingerprinting X

Notably, CMS considers currently enrolled “Home Health Agencies” to represent a Moderate risk. In comparison, CMS considers prospective (newly enrolling) home health agencies to be a High Risk. Commenting on the screening steps that CMS will be taking when dealing with providers and suppliers with a “Moderate” level of risk:

“We propose that Medicare contractors will conduct unannounced pre- and/or post-enrollment site visits in addition to those screening tools applicable to the "limited" level of risk. Based on the success of pre-and/or post enrollment site visits conducted by the NSC during the enrollment process for suppliers of DMEPOS and a similar process established by carriers and A/B MACs during the enrollment of IDTFs, we believe that unscheduled and unannounced pre-and post-enrollment site visits help ensure that suppliers are operational and meet applicable supplier standards or performance standards. In addition, we believe that unscheduled and unannounced pre-and post-enrollment site visits are an essential tool in determining whether a provider or supplier is in compliance with its reporting responsibilities, including the requirement in §424.516 to notify the Medicare contractor of any change of practice location. Moreover, §424.530(a)(5) and §424.535(a)(5) give CMS and its Medicare contractors the authority to deny or revoke Medicare billing privileges for providers and suppliers respectively if the provider or supplier is not operational or the provider does not maintain the established provider or supplier performance standards.” (emphasis added).

In addition to the screening steps to be taken, the Proposed Rule also covers the implementation of payment suspension authorities and a variety of other provisions set out in the Health Care Reform Act.

The lawyers at Liles Parker, Attorneys & Counselors at Law have extensive experience representing home health agencies. Is your home health agency being audited? For a free consultation, please give us a call at: 1 (800) 475-1906.