Program Integrity Provisions of the Affordable Care Act (ACA) for Provider Enrollment and Screening

To improve the program integrity of the Medicare, Medicaid, and the Childrens Health Insurance Program (CHIP) programs, the Patient Protection and Affordable Care Act (ACA) requires these programs to screen all enrolling and re-enrolling providers associated with the program according to the federally identified categorical risk level of a provider type. For the Iowa Medicaid Enterprise (IME), the new requirements are more extensive than the former screening requirements and include enrolling providers who were not previously required to enroll in Medicaid. The changes will allow Medicaid programs to more effectively monitor and restrict those individuals or entities who purposely defraud and abuse the Medicaid system.

Screening Levels and New Screening Requirements:

The federally identified categorical risk level of a provider type (limited, moderate, high) is based on national statistics of the provider types risk of fraud, waste or abuse. The following outlines each risk level and the corresponding new screening requirements for provider types in each risk category:

Limited Risk
Limited risk providers will be subject to verification that the provider meets applicable federal regulations or state requirements for their specific provider type, state licensure verification and database checks both before and after enrollment in order to ensure that applicable enrollment criteria are met.
Screening Requirements:
  • Provider license check List of Excluded Individuals/Entities(LEIE)
  • Check at enrollment and monthly
  • System for Award Management (SAM)
  • Information on providers who have been debarred, suspended, excluded or disqualified
  • Check at enrollment and monthly Social Security Administration (SSA) Death Master File
  • Nation-wide check National Plan and Provider Enumeration Systems (NPPES)
  • To check National Provider Identifiers Medicare Exclusion Database (MED) Medicaid and Childrens Health Insurance Program State Information Sharing System (MCSIS)
  • List of Terminated providers in all states Provider Enrollment Chain and Ownership System (PECOS)
  • Providers enrolled in Medicare
Moderate Risk
Moderate risk providers will be subject to pre- and post- enrollment site visits wherein the IME will verify that the information submitted by the provider is accurate and will determine compliance with federal and state enrollment requirements. The IME is not required to conduct site visits on those providers who have already been screened as a moderate risk provider type by Medicare or another States Medicaid or CHIP program within the previous twelve months.
Screening Requirements:
  • All screening requirements associated with the Limited risk category
  • Conduct Pre- and Post- enrollment site visits
High Risk  
High-risk providers include newly enrolling home health agencies and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers or enrolling a new practice location. In addition to those screening procedures that are conducted under the limited and moderate risk categories, these providers will be subject to criminal background checks and fingerprinting.
Screening Requirements:
  • All screening requirements associated with the Limited and Moderate risk categories
  • Conduct criminal background checks; and
  • Obtain the providers fingerprints     

Important Resources: