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Nursing home owners could face heightened background screening requirements under a proposal tucked more than 1,000 pages into a huge new proposed physician pay rule released Thursday.

The Centers for Medicare & Medicaid Services said it wants to enhance fingerprinting and other screening requirements amid recent government watchdog reports about patient abuse and Medicare fraud allowed by skilled nursing owners. The proposed rule would move skilled nursing facilities from a “limited-risk” screening category to the “high” level. 

“Given the prevalence of recent unacceptable behavior by nursing home overseers and the OIG and GAO-documented instances of nursing home beneficiary abuse, we propose to … move initially enrolling SNFs into the high-level of categorical screening; revalidating SNFs would be subject to moderate risk-level screening,” the proposal explains, referring the federal watchdog reports. “Requiring all SNF owners with 5 percent or greater ownership to submit fingerprints for a criminal background check would help us detect parties potentially posing a risk of fraud, waste, or abuse and, with this, the threat of patient abuse.”

The agency underscored that the change “would assist in protecting Medicare Trust Fund dollars and beneficiaries [and it] aligns with the Biden-Harris Administration’s initiative to improve nursing home accountability.”

In 10 pages of text, CMS outlined several examples of what it called financial malfeasance and beneficiary abuse by nursing homes as justification for the change. They ranged from providing unnecessary services to False Claims allegations and embezzlement.

“We believe that more closely scrutinizing the owners of nursing homes through our existing criminal background checks … can help detect potential criminal or abusive behavior at the nursing home before it begins,” the rule said.

“To illustrate, if a SNF owner is found through a fingerprint-based background review to have been convicted of battery, sexual assault, or other serious crime, this could raise significant concerns as to whether this conduct will be repeated during the owner’s oversight or management of the facility,” the agency wrote. “A SNF owner with an embezzlement conviction might be more inclined to divert the SNF’s funds to his personal use (and away from monies otherwise ntended for beneficiary care) than a different owner; he or she might also be more willing to tolerate malfeasance in the nursing home or to hire persons with criminal records.”

The agency already uses a fingerprint-based criminal background check system to detect prior felonious behavior by the owners of a few other types of high-risk services and supplies. They include home health agencies, durable medical supply providers, opioid treatment program suppliers and diabetes prevention program suppliers.

ACOs among points of emphasis

The 2023 Physician Fee Schedule, at 2,066 pages, also includes extensive language on redesigning accountable care organizations to make them more appealing and to encourage broader participation.

The agency called the proposed changes to its Medicare Shared Savings Program “some of the most significant reforms” since it was formally established in 2011. CMS wants to incorporate shared savings payments to select new Medicare Shared Savings Program ACOs that could be used to address Medicare beneficiaries’ social needs. 

Traditional Medicare payments are not typically allowed to be used for such purposes, though they have helped drive consumer interest in Medicare Advantage plans.

CMS also proposed that smaller ACOs have more time to transition to downside risk, which it believes could help grow participation in rural and underserved communities. The rule also includes a health equity adjustment to reward excellent care delivered to underserved populations, including dual-eligible patients. Finally, CMS is proposing benchmark adjustments to encourage more ACOs. That would further the agency’s goal of moving all traditional Medicare beneficiaries into some type of accountable care program by 2030.

The proposed rule also would significantly expand access to behavioral health services, cancer screening, and dental care — particularly in rural and underserved areas. The agency also proposed bundling  some chronic pain management and treatment services into new monthly payments, improving patient access to team-based comprehensive chronic pain treatment.