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Data Sharing Strengthens CMS Provider Screening Process

Emily Berry, for HealthLeaders Media, September 20, 2010

If you've been wondering how healthcare reform will affect your hospital's credentialing process, part of the answer may lie in new CMS regulations about terminated providers.

Specifically, the Patient Protection and Affordable Care Act of 2010 requires:

  • CMS to establish a process to make available to state Medicaid and Children's Health Insurance Program (CHIP) agencies certain information on Medicare providers and suppliers that are terminated from participating in the Medicare program or CHIP
  • States to terminate any Medicaid provider that has been terminated from participation in Medicare or another state Medicaid program

The deadline for these changes is January 1, 2011.

Credentialing professionals typically check to see if a practitioner has been excluded from Medicare and Medicaid, but not if he or she has been terminated. However, whether terminated or excluded, the bottom line for hospitals is the same: it can't collect payments on services that provider performed for Medicare and Medicaid patients.

 "Clearly, Congress decided there was a need to strengthen our screening of providers that come into and participate in the Medicaid program," says Angela Brice-Smith, director of the Medicaid Integrity Group at CMS. "If you look at all the federal health programs, we should all be doing similar things in terms of making sure we have better-performing providers in the programs serving our beneficiaries."

Brice-Smith says the Medicaid Integrity Group does not know of any state Medicaid programs that are currently sharing information about terminated Medicaid providers with one another or with Medicare. There were about 2,000 involuntary terminations of Medicaid providers and provider entities in 2008, which are the most recent data available, she says.

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