The Affordable Care Act includes numerous provisions designed to increase program integrity in Medicaid, including terminating providers from Medicaid that have been terminated in other programs, suspending Medicaid payments based on pending investigations of credible allegations of fraud, and preventing inappropriate payment of claims under Medicaid.
Areas of interest under this provision:
- Provider enrollment
- Provider participation
- Pending investigations of credible allegations of fraud
- National Correct Coding Initiative (NCCI)
- Recovery Audit Contractors (RACs)
- Home health
Provider Enrollment
Screening and enrolling providers under requirements increases program integrity in Medicaid and the Children's Health Insurance Program (CHIP).
- State Medicaid Agency Memo on CMS-6058-FC – Effective Date Change (Issued 9/25/2020)
- State Medicaid Agency Memo on CMS-6058-FC – Effective 11/20/2019
- Medicaid Provider Enrollment Compendium (MPEC) – Effective 04/15/2024
- Fingerprint-based Criminal Background Checks (FCBC): Implementation Phase Guidance from April 6, 2016 Webinar
- Affordable Care Act Program Integrity Provisions - Guidance to States - Section 6501 - Termination of Provider Participation under Medicaid if Terminated under Medicare or other State Plan (CPI –B 11-05)
- Sub Regulatory Guidance for State Medicaid Agencies (SMA): Revalidation (2016-001)
- Sub Regulatory Guidance for State Medicaid Agencies (SMA): Fingerprint-based Criminal Background Checks (FCBC) (2016-002)
- Section 6401 under Title VI Transparency and Program Integrity
- Final Rule 42 CFR Part 1007 "Medicare, Medicaid, and Children’s Health Insurance Programs; Additional Screening Requirements, Application Fees, Temporary Enrollment Moratoria, Payment Suspensions and Compliance Plans for Providers and Suppliers" - 2/2/11
- CMS sub regulatory guidance on overpayments under 42 CFR 455.450(e)
- State Medicaid Director Letter SMD#15-002 - 6/1/15
- Application Fee Matrix (correct for Medicare & Medicaid)
- Historical Documents
Provider Participation
Provider participation provisions allows for the termination of the participation of individuals or entities under Medicaid and the Children's Health Insurance Program if they have been terminated under Medicare or any other Medicaid state plan.
- Section 6501 under Title VI Transparency and Program Integrity
- Final Rule 42 CFR Part 1007 "Medicare, Medicaid, and Children’s Health Insurance Programs; Additional Screening Requirements, Application Fees, Temporary Enrollment Moratoria, Payment Suspensions and Compliance Plans for Providers and Suppliers" - 2/2/11
- CMCS Informational Bulletin - 5/31/11
Pending Investigations of Credible Allegations of Fraud
Pending Investigations of Credible Allegations of Fraud provisions ensure that federal funding is not provided to individuals or entities when there is a pending investigation of a credible allegation of fraud unless the state determines that good cause exists not to suspend such payments.
- Section 6402 under Title VI Transparency and Program Integrity
- Final Rule 42 CFR Part 1007 "Medicare, Medicaid, and Children’s Health Insurance Programs; Additional Screening Requirements, Application Fees, Temporary Enrollment Moratoria, Payment Suspensions and Compliance Plans for Providers and Suppliers" - 2/2/11
- CPI — CMCS Informational Bulletin - 3/25/11
National Correct Coding Initiative (NCCI)
Incorporating "NCCI methodologies" in state Medicaid claims processing systems promotes national correct coding methodologies and reduces improper coding that may result in inappropriate payment of claims under Medicaid.
- Section 6507 under Title VI Transparency and Program Integrity
- State Medicaid Director Letter SMD#10-017 - 9/1/10
- CMCS Informational Bulletin - 9/10/10
- HHS Report to Congress - 3/1/11
Recovery Audit Contractors (RACs)
Establishing Recovery Audit Contractors (RACs) provisions allow for auditing payments to Medicaid providers. Medicaid RACs will identify and recover provider overpayments and will also identify underpayments.
- Section 6411 under Title VI Transparency and Program Integrity
- Proposed Rule 42 CFR Part 455 "Medicaid Program; Recovery Audit Contractors" - 11/5/10
- CMCS Informational Bulletin - 11/9/10
- State Medicaid Director Letter SMDL#10-021 - 10/1/10
- CMCS Informational Bulletin - 10/1/10
Home Health
Home Health provisions document that a health care provider has had a face-to-face encounter with a patient prior to ordering the provision of home health services.
- Section 6407 under Title VI Transparency and Program Integrity
- Proposed Rule 42 CFR Parts 409, 418, 424, et al. "Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2011; Changes in Certification Requirements for Home Health Agencies and Hospices" - 7/23/10
- CMCS Informational Bulletin - 9/8/10