The Patient Protection and Affordable Care Act (PPACA) put in place several health care industry provisions to mitigate fraud and abuse in the Medicare and Medicaid programs, with an ultimate goal to contain rising health care costs. The final rule, 42 CFR 455.436, published June 1, 2016, requires states and their Medicare/Medicaid agencies to conduct federal database checks on practitioners who seek to enroll or continue participation in Medicare/Medicaid programs. Conducting federal database searches prevents inappropriate Medicare/Medicaid payments to excluded providers and reduces time-consuming and expensive ‘pay and chase’ activities.1
Under rule 42 CFR 455.436, managed care entities (payers) conduct federal database searches as part of the provider enrollment, re-enrollment or credentialing and re-credentialing processes. These databases may include, but are not limited to, the Office of Inspector General (OIG) List of Excluded Individuals and Entities (LEIE) file, the Medicare Exclusion Database (MED), the System for Award Management (formerly known as EPLS), the National Plan and Provider Enumeration System (NPPES), the State Medicaid Agency (SMA) exclusion listing and the Social Security Administration’s Death Master File (SSADMF).
The SSADMF must be searched at the time of enrollment or initial credentialing by the managed care entity/payer to ensure that Medicare/Medicaid will not be billed in the name of a deceased provider. Query of the SSADMF requires a subscription and ongoing third-party security auditing of the querying party. Query access to the SSADMF is recommended for provider enrollment staff, as well as surveillance and utilization review staff to ensure no services are paid after the death of provider or beneficiary after death.1
PCVS, one of only seven national, dually assessed Credentials Verification Organizations (CVO) by the National Committee on Quality Assurance (NCQA) and the Utilization Review Accreditation Committee (URAC), provides clients across the nation with rigorous ongoing sanction monitoring and reporting services as part of our overarching credentialing services or as a stand-alone service. In addition to monitoring of the OIG LEIE, SAM, and other state and federal sanction databases, PCVS is an authorized subscriber of the SSADMF.
Contact us today for more information on how PCVS can tailor a full suite of credentialing and/or ongoing sanction monitoring services so your organization can be assured it is meeting and exceeding all state and federal querying requirements.