Expect CMS Unannounced Visits after Filing the Revalidation Application
Do not be surprised if a CMS representative visits your agency after you apply for revalidation. Leaders are identifying that the visitors are taking pictures of the agency building and signage; taking pictures of the state license; as well as requesting copies of agency business documents.
Administrators and owners have cited the CMS representatives presenting CMS badges. Some have termed themselves as revalidation inspectors, site inspectors, and Medicare representatives while others termed themselves as Medicare Fraud Inspectors. Be certain to obtain a business card and look at the CMS badge closely. But, if you have recently sent a revalidation application, do not be surprised at the visit.
In order to be compliant with the Patient Protection and Affordable Care Act (PPACA) Section 6401, all new and existing providers must be reevaluated under the new screening guidelines delineated in the Act. These new procedures are expected to reduce fraud and abuse. For some providers, the new screening procedures will be more intense, involving the unannounced site visits, fingerprinting, and owner background investigation. For others, such as publicly traded providers, site visits are not designated.
Three Levels of Risk Assigned
In early March, 2011, CMS began basing the above interventions on a rated level of risk. There are three levels of risk per CMS; “limited,” “moderate,” and “high.”
Limited -risk providers, such a physician practices. Because there will be verification that the provider is in compliance with Federal and State guidelines, such as current licensure verification and periodic database checks prior to and following enrollment, the practices are rated limited-risk.. Also, included in the limited -risk category are ambulatory surgical centers, Indian Health Service Centers, mammography screening centers, and rural health clinics.
Moderate – risk providers, can anticipate unannounced visits. This level of provider includes community mental health centers, hospice organizations, and comprehensive outpatient rehabilitation facilities (CORFS). Home health agencies had been placed in this category however, CMS has recommended this group to be moved to the high risk category.
High – risk providers will be expected to have unannounced site visits as well as fingerprinting and thorough background reviews. Providers in this category include new DME companies and new home health agencies.
Limited and moderate risk providers can be moved to high-risk under various conditions including: allowing one provider to use another provider’s identifier within the CMS program or if a provider has had their billing privileges denied within the last 10 years.
Chapter 15, Section 19.2.1 of the “Program Integrity Manual” (PIM) CR 7350 provides the complete list of these three screening categories, and the provider types assigned to each category, as well as a description of the screening processes applicable to the three categories and procedures to be used for each category. Have your state license posted. Make certain signage is clear. Demonstrate your compliance with regulation.
We have all read about the stated recent fraudulent activities involving 78 Texas agencies and a physician who, allegedly bilked hundreds of millions from CMS. This new regulation is an additional attempt to minimize the risk of that type of fraud and abuse
To learn more about this new rule, visit: http://www.cms.gov/MLNMattersArticles/downloads/Se1126.pdf.