According to recently released documents, early in 2014, CMS plans to award a contract to perform fingerprint analysis and background checks for certain Medicare providers and suppliers. It has been nearly three years since CMS released their final rule on developing the fingerprint background check process for new DMEPOS and home health suppliers that was created as part of the Affordable Care Act. That final rule created three groups of DMEPOS and home health suppliers and their potential risk level for fraud and abusive billing. The group classification as “limited risk”, “moderate risk” and “high risk”. At this point, only those suppliers designated as “high risk” will be subject to the fingerprint background check.
According to the final rule, currently enrolled DMEPOS suppliers (which includes orthotists and prosthetists) who are subject to revalidation prior to 2015 will be classified as “moderate risk” and will not be subject to the fingerprint background check. However, newly enrolling DMEPOS suppliers will be classified as “high risk”, meaning they will be subject the fingerprint analysis and background check.
The “moderate” and “high” risk classification screening requirements and actions are listed below. For a more complete list of the provider types that are included in each category, see the link below:
Moderate screening level (currently enrolled O&P providers) When CMS designates a provider or supplier as a “moderate” categorical level of risk, the Medicare contractor does all of the following:
(i) Performs the “limited” screening requirements described in paragraph (a)(2) of this section.
(ii) Conducts an on-site visit.
High screening level (newly enrolling O&P provider) When CMS designates a provider or supplier as a “high” categorical level of risk, the Medicare contractor does all of the following:
(i) Performs the “limited” and “moderate” screening requirements described above.
(ii) Requires the submission of a set of fingerprints for a national background check from all individuals who maintain a 5 percent or greater direct or indirect ownership interest in the provider or supplier; and
(iii)Conducts a fingerprint-based criminal history record check of the Federal Bureau of Investigation’s Integrated Automated Fingerprint Identification System on all individuals who maintain a 5 percent or greater direct or indirect ownership interest in the provider or supplier.
Adjustment in the categorical risk. CMS adjusts the screening level from “limited” or “moderate” to “high” if any of the following occur:
(i) CMS imposes a payment suspension on a provider or supplier at any time in the last 10 years.
(ii) The provider or supplier— MORE