The Centers for Medicare and Medicaid Services has issued proposed rules to implement provisions of the Affordable Care Act, establishing procedures to address waste, fraud and abuse by screening providers of medical services and suppliers in the Medicare, Medicaid or CHIP programs.

CMS is specifically proposing to create designated provider and supplier categories that would be subject to certain screening procedures, based on CMS' assessment of the fraud, waste and abuse risk in the provider/supplier category.

The agency plans to designate categories of providers/suppliers with three levels of risk: "limited," "moderate" and "high." Each provider/supplier category will be assigned to one of the three levels. CMS will then set screening procedures applicable to each risk level.

The risk Levels

CMS proposes that the limited level should include physicians; nonphysician practitioners; medical clinics; group practices; a provider or supplier publicly traded on the New York Stock Exchange (NYSE) or the National Association of Securities Dealers Automated Quotation System (NASDAQ); ambulatory surgical centers; end-stage renal disease facilities; federally qualified health centers; histocompatibility laboratories; hospitals, including critical access hospitals; Indian Health Service facilities; mammography screening centers; organ procurement organizations; mass immunization roster billers, portable X-ray suppliers; religious nonmedical health care institutions; rural health clinics; radiation therapy centers; public or government owned or affiliated ambulance services suppliers; and skilled nursing facilities.

The moderate level of category would include: nonpublic, non-government owned or affiliated ambulance service suppliers; community mental health centers; comprehensive outpatient rehabilitation facilities; hospice organizations; IDTFs; and independent clinical laboratories. CMS states that the higher risk is due to the ability of such suppliers to "easily enter a line or business without clinical or business experience, for example by leasing minimal office space and equipment."

The high level category would include (unless publicly traded on the NYSE or NASDAQ), newly enrolling home health agencies and suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS), which CMS has identified as especially vulnerable to improper payments.

The screening procedures

The procedures in the proposed rule include:

More Industry Headlines