Sec. 6401. PROVIDER SCREENING AND OTHER ENROLLMENT REQUIREMENTS UNDER MEDICARE, MEDICAID, AND CHIP
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## SEC. 6401 PROVIDER SCREENING AND OTHER ENROLLMENT REQUIREMENTS UNDER MEDICARE, MEDICAID, AND CHIP ###
(a)Medicare Section 1866(j) of the Social Security Act (42 U.S.C. 1395cc(j)) is amended— ####
(1)in paragraph (1)(A), by adding at the end the following: “Such process shall include screening of providers and suppliers in accordance with paragraph (2), a provisional period of enhanced oversight in accordance with paragraph (3), disclosure requirements in accordance with paragraph (4), the imposition of temporary enrollment moratoria in accordance with paragraph (5), and the establishment of compliance programs in accordance with paragraph (6).”; ####
(2)by redesignating paragraph
(2)as paragraph (8); and ####
(3)by inserting after paragraph
(1)the following: > > #### “(2) Provider screening > > > ##### “(A) Procedures > > Not later than 180 days after the date of enactment of this paragraph, the Secretary, in consultation with the Inspector General of the Department of Health and Human Services, shall establish procedures under which screening is conducted with respect to providers of medical or other items or services and suppliers under the program under this title, the Medicaid program under title XIX, and the CHIP program under title XXI. > > > ##### “(B) Level of screening > > The Secretary shall determine the level of screening conducted under this paragraph according to the risk of fraud, waste, and abuse, as determined by the Secretary, with respect to the category of provider of medical or other items or services or supplier. Such screening— > > > ###### “(i) > > shall include a licensure check, which may include such checks across States; and > > > ###### “(ii) > > may, as the Secretary determines appropriate based on the risk of fraud, waste, and abuse described in the preceding sentence, include— > > > ###### “(I) > > a criminal background check; > > > ###### “(II) > > fingerprinting; > > > ###### “(III) > > unscheduled and unannounced site visits, including preenrollment site visits; > > > ###### “(IV) > > database checks (including such checks across States); and > > > ###### “(V) > > such other screening as the Secretary determines appropriate. > > > ##### “(C) Application fees > > > ###### “(i) Institutional providers > > Except as provided in clause (ii), the Secretary shall impose a fee on each institutional provider of medical or other items or services or supplier (such as a hospital or skilled nursing facility) with respect to which screening is conducted under this paragraph in an amount equal to— > > > ###### “(I) > > for 2010, $500; and > > > ###### “(II) > > for 2011 and each subsequent year, the amount determined under this clause for the preceding year, adjusted by the percentage change in the consumer price index for all urban consumers (all items; United States city average) for the 12-month period ending with June of the previous year. > > > ###### “(ii) Hardship exception; waiver for certain medicaid providers > > The Secretary may, on a case-by-case basis, exempt a provider of medical or other items or services or supplier from the imposition of an application fee under this subparagraph if the Secretary determines that the imposition of the application fee would result in a hardship. The Secretary may waive the application fee under this subparagraph for providers enrolled in a State Medicaid program for whom the State demonstrates that imposition of the fee would impede beneficiary access to care. > > > ###### “(iii) Use of funds > > Amounts collected as a result of the imposition of a fee under this subparagraph shall be used by the Secretary for program integrity efforts, including to cover the costs of conducting screening under this paragraph and to carry out this subsection and section 1128J. > > > ##### “(D) Application and enforcement > > > ###### “(i) New providers of services and suppliers > > The screening under this paragraph shall apply, in the case of a provider of medical or other items or services or supplier who is not enrolled in the program under this title, title XIX , or title XXI as of the date of enactment of this paragraph, on or after the date that is 1 year after such date of enactment. > > > ###### “(ii) Current providers of services and suppliers > > The screening under this paragraph shall apply, in the case of a provider of medical or other items or services or supplier who is enrolled in the program under this title, title XIX, or title XXI as of such date of enactment, on or after the date that is 2 years after such date of enactment. > > > ###### “(iii) Revalidation of enrollment > > Effective beginning on the date that is 180 days after such date of enactment, the screening under this paragraph shall apply with respect to the revalidation of enrollment of a provider of medical or other items or services or supplier in the program under this title, title XIX, or title XXI. > > > ###### “(iv) Limitation on enrollment and revalidation of enrollment > > In no case may a provider of medical or other items or services or supplier who has not been screened under this paragraph be initially enrolled or reenrolled in the program under this title, title XIX, or title XXI on or after the date that is 3 years after such date of enactment. > > > ##### “(E) Expedited rulemaking > > The Secretary may promulgate an interim final rule to carry out this paragraph. > > > #### “(3) Provisional period of enhanced oversight for new providers of services and suppliers > > > ##### “(A) In general > > The Secretary shall establish procedures to provide for a provisional period of not less than 30 days and not more than 1 year during which new providers of medical or other items or services and suppliers, as the Secretary determines appropriate, including categories of providers or suppliers, would be subject to enhanced oversight, such as prepayment review and payment caps, under the program under this title, the Medicaid program under title XIX. and the CHIP program under title XXI. > > > ##### “(B) Implementation > > The Secretary may establish by program instruction or otherwise the procedures under this paragraph. > > > #### “(4) 90-day period of enhanced oversight for initial claims of DME suppliers > > For periods beginning after January 1, 2011, if the Secretary determines that there is a significant risk of fraudulent activity among suppliers of durable medical equipment, in the case of a supplier of durable medical equipment who is within a category or geographic area under title XVIII identified pursuant to such determination and who is initially enrolling under such title, the Secretary shall, notwithstanding sections 1816(c), 1842(c), and 1869(a)(2), withhold payment under such title with respect to durable medical equipment furnished by such supplier during the 90-day period beginning on the date of the first submission of a claim under such title for durable medical equipment furnished by such supplier. > > > #### “(5) Increased disclosure requirements > > > ##### “(A) Disclosure > > A provider of medical or other items or services or supplier who submits an application for enrollment or revalidation of enrollment in the program under this title, title XIX, or title XXI on or after the date that is 1 year after the date of enactment of this paragraph shall disclose (in a form and manner and at such time as determined by the Secretary) any current or previous affiliation (directly or indirectly) with a provider of medical or other items or services or supplier that has uncollected debt, has been or is subject to a payment suspension under a Federal health care program (as defined in section 1128B(f)), has been excluded from participation under the program under this title, the Medicaid program under title XIX, or the CHIP program under title XXI, or has had its billing privileges denied or revoked. > > > ##### “(B) Authority to deny enrollment > > If the Secretary determines that such previous affiliation poses an undue risk of fraud, waste, or abuse, the Secretary may deny such application. Such a denial shall be subject to appeal in accordance with paragraph (7). > > > #### “(6) Authority to adjust payments of providers of services and suppliers with the same tax identification number for past-due obligations > > > ##### “(A) In general > > Notwithstanding any other provision of this title, in the case of an applicable provider of services or supplier, the Secretary may make any necessary adjustments to payments to the applicable provider of services or supplier under the program under this title in order to satisfy any past-due obligations described in subparagraph (B)(ii) of an obligated provider of services or supplier. > > > ##### “(B) Definitions > > In this paragraph: > > > ###### “(i) In general > > The term ‘**applicable provider of services or supplier**’ means a provider of services or supplier that has the same taxpayer identification number assigned under section 6109 of the Internal Revenue Code of 1986 as is assigned to the obligated provider of services or supplier under such section, regardless of whether the applicable provider of services or supplier is assigned a different billing number or national provider identification number under the program under this title than is assigned to the obligated provider of services or supplier. > > > ###### “(ii) Obligated provider of services or supplier > > The term ‘**obligated provider of services or supplier**’ means a provider of services or supplier that owes a past-due obligation under the program under this title (as determined by the Secretary). > > > #### “(7) Temporary moratorium on enrollment of new providers > > > ##### “(A) In general > > The Secretary may impose a temporary moratorium on the enrollment of new providers of services and suppliers, including categories of providers of services and suppliers, in the program under this title, under the Medicaid program under title XIX, or under the CHIP program under title XXI if the Secretary determines such moratorium is necessary to prevent or combat fraud, waste, or abuse under either such program. > > > ##### “(B) Limitation on review > > There shall be no judicial review under section 1869, section 1878, or otherwise, of a temporary moratorium imposed under subparagraph (A). > > > #### “(8) Compliance programs > > > ##### “(A) In general > > On or after the date of implementation determined by the Secretary under subparagraph (C), a provider of medical or other items or services or supplier within a particular industry sector or category shall, as a condition of enrollment in the program under this title, title XIX, or title XXI, establish a compliance program that contains the core elements established under subparagraph
(B)with respect to that provider or supplier and industry or category. > > > ##### “(B) Establishment of core elements > > The Secretary, in consultation with the Inspector General of the Department of Health and Human Services, shall establish core elements for a compliance program under subparagraph
(A)for providers or suppliers within a particular industry or category. > > > ##### “(C) Timeline for implementation > > The Secretary shall determine the timeline for the establishment of the core elements under subparagraph
(B)and the date of the implementation of subparagraph
(A)for providers or suppliers within a particular industry or category. The Secretary shall, in determining such date of implementation, consider the extent to which the adoption of compliance programs by a provider of medical or other items or services or supplier is widespread in a particular industry sector or with respect to a particular provider or supplier category.” > . ###
(b)Medicaid ####
(1)State plan amendment Section 1902(a) of the Social Security Act (42 U.S.C. 1396a(a)), as amended by section 4302(b), is amended— #####
(A)in subsection (a)— ######
(i)by striking “and” at the end of paragraph (75); ######
(ii)by striking the period at the end of paragraph
(76)and inserting a semicolon; and ######
(iii)by inserting after paragraph
(76)the following: > > #### “(77) > > provide that the State shall comply with provider and supplier screening, oversight, and reporting requirements in accordance with subsection (ii);” > ; and #####
(B)by adding at the end the following: > > ### “(ii) Provider and supplier screening, oversight, and reporting requirements > > For purposes of subsection (a)(77), the requirements of this subsection are the following: > > > #### “(1) Screening > > The State complies with the process for screening providers and suppliers under this title, as established by the Secretary under section 1886(j)(2). > > > #### “(2) Provisional period of enhanced oversight for new providers and suppliers > > The State complies with procedures to provide for a provisional period of enhanced oversight for new providers and suppliers under this title, as established by the Secretary under section 1886(j)(3). > > > #### “(3) Disclosure requirements > > The State requires providers and suppliers under the State plan or under a waiver of the plan to comply with the disclosure requirements established by the Secretary under section 1886(j)(4). > > > #### “(4) Temporary moratorium on enrollment of new providers or suppliers > > > ##### “(A) Temporary moratorium imposed by the Secretary > > > ###### “(i) In general > > Subject to clause (ii), the State complies with any temporary moratorium on the enrollment of new providers or suppliers imposed by the Secretary under section 1886(j)(6). > > > ###### “(ii) Exception > > A State shall not be required to comply with a temporary moratorium described in clause
(i)if the State determines that the imposition of such temporary moratorium would adversely impact beneficiaries' access to medical assistance. > > > ##### “(B) Moratorium on enrollment of providers and suppliers > > At the option of the State, the State imposes, for purposes of entering into participation agreements with providers or suppliers under the State plan or under a waiver of the plan, periods of enrollment moratoria, or numerical caps or other limits, for providers or suppliers identified by the Secretary as being at high-risk for fraud, waste, or abuse as necessary to combat fraud, waste, or abuse, but only if the State determines that the imposition of any such period, cap, or other limits would not adversely impact beneficiaries' access to medical assistance. > > > #### “(5) Compliance programs > > The State requires providers and suppliers under the State plan or under a waiver of the plan to establish, in accordance with the requirements of section 1866(j)(7), a compliance program that contains the core elements established under subparagraph
(B)of that section 1866(j)(7) for providers or suppliers within a particular industry or category. > > > #### “(6) Reporting of adverse provider actions > > The State complies with the national system for reporting criminal and civil convictions, sanctions, negative licensure actions, and other adverse provider actions to the Secretary, through the Administrator of the Centers for Medicare & Medicaid Services, in accordance with regulations of the Secretary. > > > #### “(7) Enrollment and npi of ordering or referring providers > > The State requires— > > > ##### “(A) > > all ordering or referring physicians or other professionals to be enrolled under the State plan or under a waiver of the plan as a participating provider; and > > > ##### “(B) > > the national provider identifier of any ordering or referring physician or other professional to be specified on any claim for payment that is based on an order or referral of the physician or other professional. > > > #### “(8) Other state oversight > > Nothing in this subsection shall be interpreted to preclude or limit the ability of a State to engage in provider and supplier screening or enhanced provider and supplier oversight activities beyond those required by the Secretary.” > . ####
(2)Disclosure of Medicare terminated providers and suppliers to states **[**[42 U.S.C. 1395cc note](/us/usc/t42/s1395cc)**]** The Administrator of the Centers for Medicare & Medicaid Services shall establish a process for making available to the each State agency with responsibility for administering a State Medicaid plan (or a waiver of such plan) under title XIX of the Social Security Act or a child health plan under title XXI the name, national provider identifier, and other identifying information for any provider of medical or other items or services or supplier under the Medicare program under title XVIII or under the CHIP program under title XXI that is terminated from participation under that program within 30 days of the termination (and, with respect to all such providers or suppliers who are terminated from the Medicare program on the date of enactment of this Act, within 90 days of such date). ####
(3)Conforming amendment Section 1902(a)(23) of the Social Security Act (42 U.S.C. 1396a), is amended by inserting before the semicolon at the end the following: “or by a provider or supplier to which a moratorium under subsection (ii)(4) is applied during the period of such moratorium”. ###
(c)CHIP Section 2107(e)(1) of the Social Security Act (42 U.S.C. 1397gg(e)(1)), as amended by section 2101(d), is amended— ####
(1)by redesignating subparagraphs
(D)through
(M)as subparagraphs
(E)through (N), respectively; and ####
(2)by inserting after subparagraph (C), the following: > > ##### “(D) > > Subsections (a)(77) and
(ii)of section 1902 (relating to provider and supplier screening, oversight, and reporting requirements).” > .
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Sec. 6401
PROVIDER SCREENING AND OTHER ENROLLMENT REQUIREMENTS UNDER MEDICARE, MEDICAID, AND CHIP
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