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.
Until CMS establishes the new information sharing process, medical staffs can find out whether Medicare has terminated a practitioner by asking the practitioner to self-report or by filing a Freedom of Information Act request with CMS. There is no government website that posts this information, in contrast to the OIG’s List of Excluded Individuals/Entities.
After the new process goes into effect, credentialing professionals will no longer need to separately query Medicare and Medicaid regarding terminated providers; one query to Medicare will uncover all available information.
When CMS completes the new system to share information about terminated providers, credentialing specialists will have one more source to verify the quality of the practitioners they are credentialing and ensure that the hospital will receive reimbursement for services rendered.