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CMS: States Must Start Screening Medicaid Providers

Posted on Wednesday, June 3, 2015 9:52 AM

According to new guidance from CMS, states have until the end of July to start screening high-risk Medicaid and Children’s Health Insurance Program providers. The screenings will be fingerprint-based criminal background checks and should be completed by June 1, 2016. Once a state Medicaid agency has been identified as “high” risk, or susceptible to improper payments, the implementation of background checks will occur. Additionally, if a provider is labeled as “high” risk by Medicare, the state Medicaid agency must also consider it “high” risk. Once a provider is determined as high risk by a state agency, it is required to consent to a criminal background check, including fingerprinting. This requirement also applies to anyone with a 5% or more direct or indirect ownership interest in the provider. The Affordable Care Act published a final rule in 2011 to identify the different levels of risk, stating that Medicaid agencies must establish risk levels for providers who had an increased risk of fraud. The final rule did not specify the criteria of each risk, leaving the responsibility to the states. Click here to read more.   Go Back