Dive Brief:
- Beginning Aug. 1, providers who are considered to be at "high risk" for Medicaid fraud must submit to criminal background checks, including fingerprinting.
- All state Medicaid and CHIP providers have until March of next year to rank all of their providers as limited, moderate or high risk for defrauding the program.
- Providers will be re-ranked at least once every five years.
Dive Insight:
The final rule requiring background checks for high-risk Medicaid providers was released in 2011 as part of the Affordable Care Act. It is unclear why there has been a four-year delay in implementatation.
For the most part, states will be able to rank providers at their own discretion, although executives who have at least 5% direct or indirect ownership of newly-enrolled home healthcare or durable medical equipment agencies will automatically be considered high risk. CMS will also change a provider's ranking to high risk if the provider is subject to a payment suspension or has had its billing privileges revoked within the last 10 years.
States are also required to deny or terminate enrollment of high-risk providers who refuse to submit to the background check, including fingerprints, within 30 days of request and in the manner requested by the state Medicaid agency. Those who have been convicted of defrauding Medicaid, Medicare or CHIP in the past and those who are facing certain felony charges (e.g., murder, rape, money-related crimes) will also be excluded from participating in Medicaid programs.