CMS recently released guidance on the rollout of their new fingerprint background check requirement for certain DMEPOS providers. It has been more than three years since CMS released their final rule on developing a fingerprint background check process for new DMEPOS and home health suppliers that was created as part of the Affordable Care Act.
The final rule created three groups of DMEPOS and home health suppliers and their potential risk level for fraud and abusive billing. The group classifications are “limited risk”, “moderate risk” and “high risk”. At this point, this initiative is limited to 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.
Additionally, as you will see below, there are other ways a supplier can be moved into the “high risk” category that include CMS payment suspensions going back 10 years and several other similar distinctions that would require an existing O&P practitioner to be subject to the new fingerprint rules.
The “moderate” and “high” risk classification screening requirements and actions are listed 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.(3) Adjustment in the categorical risk. CMS adjusts the screening level from “limited” or “moderate” to “high” if any of the following occur:(B) Had billing privileges revoked by a Medicare contractor within the previous 10 years and is attempting to establish additional Medicare billing privileges by—(1) Enrolling as a new provider or supplier; or(2) Billing privileges for a new practice location;(E) Has been subject to any final adverse action, as defined at § 424.502, within the previous 10 years.(iii) CMS lifts a temporary moratorium for a particular provider or supplier type and a provider or supplier that was prevented from enrolling based on the moratorium, applies for enrollment as a Medicare provider or supplier at any time within 6 months from the date the moratorium was lifted. MORE