Provider Enrollment
and the Affordable Care Act
HP Provider Relations
May 2012
Agenda
– Session Objectives
– Provider Enrollment Web Pages
– Affordable Care Act (ACA) Impact
– Risk Levels
– Revalidation
– Disclosed Individuals
– Profile Updates
– Provider Screening
– Background Checks
– Associated Fees
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Provider Enrollment and the ACA
May 2012
Objectives
– Know the screening tasks that apply to your provider type
– Understand the impact of your assigned risk level
– Understand the revalidation process
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Provider Enrollment and the ACA
May 2012
On the Web
Indianamedicaid.com
Affordable Care Act
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Provider Enrollment and the ACA
May 2012
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Select your
provider type
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Choose
an
update
form
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Define
What is the ACA?
Affordable Care Act
Impact on Provider Enrollment
– Centers for Medicare & Medicaid Services (CMS) Rule 6028-FC of the
ACA provides procedures under which screening activities are
performed for providers in Medicare and state Medicaid programs.
– Screening activities place heightened emphasis on program integrity
designed to reduce fraud, waste, and abuse in the Medicare and
Medicaid programs.
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Provider Enrollment and the ACA
May 2012
Affordable Care Act
Impact on Provider Enrollment
– On January 1, 2012, the Indiana Health Coverage Programs (IHCP)
adopted and enacted new provider enrollment and screening
requirements mandated by the ACA.
– Screening and pre-enrollment procedures are applicable to:
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New providers enrolling for the first time
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Re-enrollments due to a change of ownership
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Existing providers adding new service locations; and,
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Existing providers revalidating their enrollment.
Provider Enrollment and the ACA
May 2012
Identify
Risk Levels
Risk Levels
– All provider types and specialties are assigned to one of the following risk
levels. Waiver providers are assigned risk levels at the subspecialty level.
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High
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Moderate
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Limited
– Providers are subject to screening tasks based on their assigned risk level
– The risk level categorization is established by the CMS, based on an assessment of potential
for fraud, waste, and abuse for each provider type/specialty
– The risk level assignment may be increased at any time at the discretion of the State. In these
instances, the provider will be notified by the State, and the new risk level will apply to processing
enrollment-related transactions.
– The Provider Type Application Fee and Risk Assignment Matrix (for NonWaiver and Waiver providers) provides a full list of provider types and
their assigned risk level.
NOTE: Review this document before revalidating to review current requirements
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Provider Enrollment and the ACA
May 2012
Risk Levels
Risk level – High
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Risk Level High
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Provider Enrollment and the ACA
May 2012
Newly enrolling home health agency (HHA)
Newly enrolling hearing aid dealer
Newly enrolling pharmacy with DME or HME
specialty
Newly enrolling DME supplier
Newly enrolling nonemergency transportation
provider
Newly enrolling waiver specialized medical
equipment and supplies provider
Newly enrolling waiver attendant care
providers
Risk Levels
Risk level – Moderate
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Risk Level Moderate
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Provider Enrollment and the ACA
May 2012
Rehabilitation facility with comprehensive
outpatient rehab facility specialty
Revalidating home health agency
Hospice
Clinic with therapy clinic specialty
Mental health provider with Community
Mental Health Center (CMHC) specialty
Physical therapist
Revalidating hearing aid dealer
Revalidating pharmacy with DME/HME
specialty
Revalidating DME supplier
Ambulance and air ambulance provider
Revalidating nonemergency transportation
provider
Risk Levels
Risk level – Moderate
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Independent lab, mobile lab, independent
diagnostic testing facility (IDTF), mobile IDTF
• Mobile x-ray clinic
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Revalidating waiver provider offering
specialized medical equipment and supplies,
or waiver physical therapy provider
• Revalidating waiver attendant care provider
Risk Level Moderate
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New waiver consultative clinical and
therapeutic service provider
• Newly enrolling waiver flex funds provider
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Provider Enrollment and the ACA
May 2012
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Waiver Community Alternatives to Psychiatric
Residential Treatment Facilities (CA-PRTF)
habilitation providers
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Waiver wraparound facilitation care
coordinators
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Waiver wraparound technicians
Risk Levels
Risk level – Limited
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Risk Level
- Limited
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Provider Enrollment and the ACA
May 2012
Hospital
Ambulatory surgical center (ASC)
Extended care facility
Federally Qualified Health Center (FQHC)
Rural health clinic (RHC)
Advanced practice nurse (APN)
Pharmacy
Dentist
End-stage renal disease clinic (ESRD)
Physician
Clinic
Birthing center
Risk Levels
Risk level – Limited
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Risk Level
- Limited
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Provider Enrollment and the ACA
May 2012
Physician assistant (not currently enrolled)
Outpatient mental health clinic
health service provider in psychology (HSPP)
School corporation
Public health agency
Podiatrist
Chiropractor
Occupational therapist
Speech/hearing therapist
Optometrist
Optician
Audiologist
Risk Levels
Risk level – Limited
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Risk Level
- Limited
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Provider Enrollment and the ACA
May 2012
Case manager
Family member transportation provider
Free-standing X-ray clinic
All waiver providers not listed as High or
Moderate risk
Extended care facility
Rehabilitation facility
Medical clinic
Family planning clinic
Nurse practitioner clinic
Dental clinic
Revalidation
Revalidation
– Revalidation will initially impact all providers and suppliers that were
enrolled in the IHCP prior to January 1, 2012.
– Providers enrolled in the IHCP after January 1, 2012, will be required
to revalidate beginning calendar year 2017 (CY 2015 for DME and
HME providers).
– All states are required to revalidate enrolled providers at intervals not
to exceed every five years.
– Durable and Home Medical Equipment providers and pharmacy
providers that have DME/HME specialties will revalidate at intervals
not to exceed every three years.
– Revalidating providers are subject to all required screening activities
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Provider Enrollment and the ACA
May 2012
Revalidation Timeline
– In March 2012, the IHCP began revalidating providers in phases
based on provider type.
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Provider revalidation is scheduled for completion December 31, 2015.
– Providers will receive notification 90 days prior to their respective
deadline to revalidate.
– Notifications for revalidation will be sent to the ‘Mail To’ address listed
on the provider’s profile.
– Providers are encouraged to verify their ‘Mail To’ address on file by
accessing the Provider Profile feature of Web interChange.
– Providers who have not submitted their paperwork to the IHCP at 60
days from their notification deadline will receive a second notice.
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Provider Enrollment and the ACA
May 2012
Revalidation Notification
– Providers that fail to answer notifications prior to their respective
deadlines will be disenrolled from IHCP participation.
– Claims billed with dates of service on or after the deadline or
disenrollment date will be denied.
– Managed care members assigned to a primary medical provider (PMP)
will be automatically reassigned to another PMP.
– Level of care members will lose benefits.
– Disenrolled providers that submit revalidation materials and meet all
federal and state guidelines will be re-enrolled in the IHCP.
– Back-dating enrollments for once-disenrolled providers is prohibited.
Providers are highly encouraged to return
revalidation paperwork timely.
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Provider Enrollment and the ACA
May 2012
Revalidation Notification
– Web interChange users will be able to view the providers’ Service
Location name, address, and revalidation deadline for those that are
due for revalidation.
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Users must have “View” access within Provider Profile to see the list of names.
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Provider names will be listed under the View Upcoming Providers for Revalidation link
under the Provider Profile feature.
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Providers’ names will be removed from the list when the revalidation deadline passes.
Provider Enrollment and the ACA
May 2012
Revalidation Notification
Select the link to
view a list of
providers due for
revalidation
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Provider Enrollment and the ACA
May 2012
Revalidation Notification
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Provider Enrollment and the ACA
May 2012
Revalidation vs. Recertification
– Revalidation
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Required by the Affordable Care Act
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Required for all currently enrolled providers at intervals of three or five years
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Involves completing a new enrollment application
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Requires performance of all risk-appropriate screening activities
Provider Enrollment and the ACA
May 2012
Revalidation vs. Recertification
– Recertification
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Required by the State of Indiana
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Required for currently enrolled out-of-state providers of certain specialties
− Hospital – Upon renewal of license or Joint Commission on the Accreditation of Healthcare Organizations
(JCAHO) certification
− Some Extended Care Facilities – Annual submission of a newly signed Provider Agreement
− Ambulance – Upon issuance of a renewed Emergency Medical Service (EMS) certificate or EMS Air Ambulance
certificate
− Transportation – Upon issuance of a renewed Motor Carrier Services (MCS) certificate/operating authority or
Livery license and insurance policy
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Requires completion of the IHCP Provider Recertification Form
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Does not require completion of a new enrollment application
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Does not require completion of screening activities
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Does not require payment of the application fee
Provider Enrollment and the ACA
May 2012
Define
Disclosed Individuals
Disclosed Individuals
Paper Enrollment Application
– Schedule C, sections C.1 through C.3 of the IHCP Provider Enrollment
Application collects the names of disclosed individuals.
– Disclosure information refers to the identification of:
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Business owners
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Officers
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Managers
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Members of the Board of Directors
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Managers responsible for day-to-day operations
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Subcontractors
– The ACA mandates background checks for those with a 5% or more
ownership in a High risk provider entity
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Provider Enrollment and the ACA
May 2012
Disclosed Individuals
Web interChange
– Disclosure information is also collected via the Provider Profile feature
of Web interChange.
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Applies to providers assigned to the limited risk category only
– A field has been added to Web interChange Provider Profile to
capture, store, and display the date of birth for all disclosed
individuals.
– Web interChange requires the addition of the date of birth for new
entries and updates to existing entries for disclosed individuals and
rendering providers.
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Provider Enrollment and the ACA
May 2012
Disclosure Information
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Provider Enrollment and the ACA
May 2012
Profile Updates
Profile Updates
– For providers assigned to the high and moderate risk levels, the
following Web interChange updates are not allowed:
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Service Location address change
− Unannounced, unscheduled site visits will be conducted before the address change is approved
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Addition and removal of names from the disclosure information
− Disclosed individuals are subject to screening activities before changes are approved
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Addition of Specialty
− Those that acquire a higher-risk specialty than previously assigned may not update on Web interChange
Note: These profile updates must be performed using the paper forms
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Provider Enrollment and the ACA
May 2012
Profile Updates
Paper maintenance forms
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Providers may continue to use paper update forms to perform maintenance to their
profile.
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Modifications have been made to the following maintenance forms:
− IHCP Name Address Maintenance Form
− IHCP Claim Certification Statement for Signature on File Addendum
− IHCP CLIA Certification Maintenance Form
− IHCP Delegated Administrator Addendum
− IHCP Electronic Funds Transfer Addendum
− IHCP Medicare Number Maintenance Form
− IHCP Recertification Form
− IHCP Disenrollment Form
− IHCP Specialty Maintenance Form
− IHCP Tax Identification Maintenance Form
− IHCP Psychiatric Hospital Bed Addendum
− IHCP PRTF Attestation Letter Information
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Provider Enrollment and the ACA
May 2012
Modifications include the addition
of Social Security Number and
date of birth fields, a fee payment
form and background/fingerprint
check form.
Screen
Due Diligence
Provider Screening
Screening tasks
– Prior to completing enrollment processing, providers are subject to
screening tasks based on their risk category.
– High risk category :
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Unscheduled, unannounced site visits
− Site visits are conducted prior to and after an approved enrollment
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Fingerprint-based background check of disclosed individuals with a 5% or more
ownership interest
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Validation of disclosed individuals with the Office of the Inspector General (OIG)
Excluded Individuals database, the Excluded Parties List System (EPLS) and the
Social Security Death Master List
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License verification
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Proof of Medicare enrollment, if Medicare-enrolled with Medicare Provider Enrollment
Chain and Ownership System (PECOS)
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Validation of the National Provider Identifier (NPI) with the National Plan and Provider
Enumeration System (NPPES)
Provider Enrollment and the ACA
May 2012
Provider Screening
Screening tasks
– Moderate risk category
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Unscheduled, unannounced site visits
− Site visits are conducted prior to and after an approved enrollment
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Validation of disclosed individuals with the OIG Excluded Individuals database, the
EPLS and Social Security Death Master List
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License verification
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Proof of Medicare enrollment, if Medicare-enrolled
– Limited risk category :
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Validation of disclosed individuals with the OIG Excluded Individuals database, the
EPLS and Social Security Death Master List
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License verification
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Proof of Medicare enrollment, if Medicare-enrolled
– All screening tasks for all risk categories are performed for each
service location individually
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Provider Enrollment and the ACA
May 2012
Provider Screening
Database checks
– The names of disclosed individuals for currently enrolled providers are
validated on the EPLS, OIG, Social Security Death Master List,
NPPES, PECOS, and MCSIS databases on a monthly basis.
– The Excluded Parties List System identifies individuals that are
debarred, suspended, excluded, or disqualified from receiving federal
contracts, subcontracts, financial, and nonfinancial assistance and
benefits.
– The OIG Exclusion List identifies individuals that are excluded from
participation in Medicare, Medicaid, and Title XX programs.
– The Social Security Death Master List is the national repository to
validate that an individual is deceased.
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Provider Enrollment and the ACA
May 2012
Provider Screening
Database checks
– NPPES is a database of NPIs assigned to healthcare providers
– PECOS is the provider enrollment system used by Medicare
– Medicaid and CHIP State Information Sharing System (MCSIS)
database identifies individuals excluded from participation in other
State’s Medicaid programs
– These providers are not eligible to participate in the IHCP.
– Providers that were sanctioned by the OIG are not eligible to enroll in
the IHCP.
– Bulletin BT200934 reminds providers of their responsibility to screen
disclosed individuals and employees prior to hiring and periodically
thereafter.
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Provider Enrollment and the ACA
May 2012
Background Check
Background Check
– Disclosed individuals with a 5% or more ownership in a “high risk”
provider entity are required to undergo a fingerprint-based background
investigation.
– The IHCP will utilize LexisNexis to provide fingerprint-based
background investigation services.
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Provider Enrollment and the ACA
May 2012
Background Check
Process
– Disclosed individuals access the links on indianamedicaid.com to
make arrangements for fingerprinting.
– Disclosed individuals will make an appointment at a nearby collection
site using the links on indianamedicaid.com .
– Fingerprints are sent electronically to the Federal Bureau of
Investigation (FBI) for processing.
– The FBI will return the Criminal History Reports to the IHCP.
– Each disclosed individual requiring fingerprinting will pay a separate
$25.00 administration fee to the fingerprint collection site.
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Provider Enrollment and the ACA
May 2012
Describe
Application Fees
Fees
– The CMS sets the application fee amount annually; the fee for 2012 is
$523.
– A $523 application fee will be collected from providers (as defined by
CMS) that have not paid the application fee to Medicare, or who have
not paid the fee to another state Medicaid program.
– Out of state providers that enroll or revalidate with the IHCP must
provide proof of payment of the application fee if paid to their state’s
Medicaid program.
– The application fee applies to newly enrolling and revalidating
providers, entities executing a change of ownership, those adding or
changing to a higher-risk specialty, and existing providers adding a
new service location.
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Provider Enrollment and the ACA
May 2012
Fees
– Application fee
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Institutional providers will pay a fee to enroll in the Medicare or Medicaid programs.
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Dually enrolled providers will pay the fee only to Medicare.
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Medicaid-only providers will pay the fee to Medicaid.
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Each service location must pay the fee upon enrolling and revalidating.
• Review the Risk Category and Application Fee Matrix at
http://provider.indianamedicaid.com/media/27745/matrix.pdf to determine if an
application fee is required for your provider type.
• Payment methods include:
− Check
− Money order
− Credit/debit card using HP Convenience Pay
− Electronic check including Automated Clearing House (ACH) and electronic funds transfer (EFT)
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Provider Enrollment and the ACA
May 2012
Fees
– The IHCP will use HP Convenience Pay to process credit/debit card
payments of the application fee.
– The Convenience Pay Services Client Access Portal provides
authorized users with online, real-time access to ACH/EFT self-service
capabilities.
– HP Convenience Pay can be accessed via indianamedicaid.com or
https://www.paybill.com/ClientAccessPortal/Login.aspx.
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Provider Enrollment and the ACA
May 2012
Find Help
Resources Available
Helpful Tools
Avenues of resolution
– Provider Enrollment page at
indianamedicaid.com
– HP Convenience Pay
https://www.paybill.com/ClientAccess
Portal/Login.aspx
– IHCP Provider Manual, Chapter 4
(Web, CD-ROM, or paper)
– Provider Bulletin BT201151
– Provider Enrollment Phone Line
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1-877-707-5750
– Provider field consultant
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provider.indianamedicaid.com/contactus/provider-relations-field-consultants.aspx
Provider Enrollment and the ACA
May 2012
Q&A