CMS may require more stringent provider screening for Medicare, Medicaid enrollment, participation

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Some healthcare providers would be subject to criminal background checks and fingerprinting under a new fraud-prevention plan from the Centers for Medicare & Medicaid Services.

Under the proposed rule, providers and suppliers would have to undergo stricter screening to enroll or participate in Medicare and Medicaid. They would be assessed for their risk of fraud, waste and abuse, and placed in one of three risk groups: limited risk, moderate risk and high risk. Limited-risk providers, which the proposed rule considers skilled nursing facilities, physician groups and other state-registered practitioners, would be required to verify licensing information, Social Security numbers and other such Medicare and Medicaid requirements.

High-risk providers, which the rule considers home health providers and suppliers of durable medical equipment, would be subject to more rigorous criminal background checks and fingerprinting. This would be in addition to the other Medicare and Medicaid requirements as a condition of enrollment and participation in federal programs.

These rigorous background checks could help prevent fraud before it happens, Berwick said at a press briefing Monday. CMS is hoping to shift from a “pay-and-chase” enforcement model to a preventative enforcement model. The rule will be published Sept. 23 in the Federal Register; comments are due by Nov. 16.