Accreditation Mandatory for Providers in Medicare Fraud Demo

ATLANTA–HME providers in Southern California and South Florida
will be required to become accredited within a 90-day period under
a stipulation in the massive anti-fraud demonstration to be
implemented in those areas by CMS.

Providers who do not become accredited within that time after
receiving notification from the National Supplier Clearinghouse to
do so will lose their Medicare billing numbers, according to
details of the initiative.

The requirement has stirred up industry stakeholders, who
protested that it is an unreasonable standard.

“You can’t get accredited in 90 days,” said Miriam Lieber of
Lieber Consulting in Sherman Oaks, Calif. “You have to have four
months of records; you can barely get the surveyors out [in that
period of time] … This is just not feasible.”

“I don’t think it can be done in 90 days,” agreed Mary Ellen
Conway, president of Capital Healthcare Group, Bethesda, Md. “There
is such a thing as a provisional accreditation for new companies,
but not for existing companies. It’s shocking to think that the NSC
thinks this can be done in 90 days.”

Under CMS’ two-year initiative, which is designed to prevent
deceptive home care companies from operating in the greater Los
Angeles and Miami areas, about 7,700 providers will be required to
reapply for their Medicare billing numbers within 30 days of
receiving a notice from CMS to re-enroll. (See HomeCare Monday, July 9.)

Those that remain in the system will be subject to “intense
review,” CMS officials said when they announced the project on July
2. That process will include multiple unannounced site visits by
NSC investigators, as well as a “fraud level indicator” for each
provider that considers such factors as:

–Experience as a DMEPOS supplier with other payers;
–Prior Medicare experience;
–Specific supplier location;
–Fraud potential of products and services listed;
–Site visit results;
–Inventory observed and contracted; and
–Accreditation of the supplier.

Revocation of billing privileges will occur if “the DMEPOS
supplier failed to obtain accreditation from an approved DMEPOS
accrediting organization within 90 days of notification from the
NSC to do so,” according to the demonstration rules.

Providers and consultants quizzed NSC officials during a
conference call last week, asking how the timeline could be met
given the requirements of accreditation. NSC officials responded
that they did not know the details, but that the 90-day time
stipulation was what was planned. When contacted by
HomeCare, the NSC declined comment.

Conway said full accreditation could conceivably be achieved in
120 days. “It would still be a challenge, and it would have to be
tightly watched, but it’s doable,” she said.

Tim Safley, HME clinical advisor for the Accreditation
Commission for Health Care in Raleigh, N.C., one of CMS’ 10
approved DMEPOS accrediting organizations, said the 90-day limit
could work, but only if the company was in the process of becoming
accredited already. If companies in the demonstration areas have
not applied, he added, “they’ve got to get started now. Those
companies that wait are going to be put by the wayside.”

“They needed to be accredited yesterday,” Lieber said
bluntly.

Both Lieber and Safley noted that questions still remain about
the fraud initiative, including whether the NSC will recognize
pending accreditation or whether the company must be fully
accredited within the 90 days.

Providers might buy a bit of time depending on when CMS sends
its re-enrollment notification letters. No set date was given in
the demonstration announcement, although an agency official said
the letters would be sent within three to four months.

However, the consultants said, the handwriting is not only on
the wall, it is in large, blinking, neon letters: Providers must
become accredited, and it is unwise to delay the process any
longer.

“There is no legislation [pending] to stop accreditation,”
Safley said. “It’s not going away. If people wait, they are going
to miss the window.”

CMS is expected to announce a deadline soon by which all
providers who bill Medicare will need to be accredited; those in
the first round of competitive bidding must be accredited by Aug.
31 in order to win a contract.

Conway pointed out that it isn’t just Medicare providers who
will be affected by mandatory accreditation. “You have to keep in
mind all your payers,” she said. “It’s going to affect everyone,
even if they don’t do Medicare. As Medicare goes, so go all the
other payers.”

Indeed, late last month, Medicaid providers in Oklahoma received
a letter from the state’s Health Care Authority that said effective
Jan.1, 2008, all DMEPOS suppliers “must be accredited by a
Medicare-deemed accreditation organization for quality standards
for DMEPOS suppliers in order to bill the SoonerCare program.”

The state agency said it was making the policy revision to
“comply with the [CMS] accreditation standards.”

While CMS’ two-year fraud initiative could expand to additional
areas depending on its success in Miami and L.A., the agency is
already planning to implement a similar demonstration project
focusing on home health agencies in Harris County (Houston), Texas,
and four California counties in the greater Los Angeles area: Los
Angeles, Orange, Riverside and San Bernardino.

Under that initiative, announced Tuesday, HHAs in those areas
must also re-enroll within 60 days after being requested to do so
and must adhere to certain standards. They will also be subject to
on-site reviews and, if they have changed ownership within the last
two years, a survey.

For an HHS fact sheet on CMS’ DME fraud demonstration project,
click here.

For a fact sheet on the HHA fraud initiative, click here.