Program Integrity
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.
Provider Participation: Terminating 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: Ensuring 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 to promote correct coding and control improper coding leading to 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) to audit 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: Documenting 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