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Frequent Findings Toolkits for Program Integrity Reviews

Section 1936 of the Social Security Act requires CMS to provide support and assistance to state Medicaid program integrity efforts. To fulfill this requirement, CMS began conducting comprehensive state program integrity reviews in 2007.  The reviews identify problems that warrant improvement or correction in state operations and provide technical assistance to states to correct those problems.

CMS has identified that the most frequent findings from state program integrity reviews are in the area of provider enrollment, both in fee-for-service and managed care. Findings include issues with provider disclosures of ownership and control, business transactions, and criminal convictions; federal database checks for excluded parties; and the reporting of adverse actions taken against providers to the U.S. Dept. of Health and Human Services-Office of Inspector General (HHS OIG).  As another means of providing assistance to states, CMS has developed the following five toolkits to address these frequent findings. Toolkits are designed to help states better understand the requirements and improve compliance with federal regulations.  The toolkits identify common issues observed and provide practical solutions that states can implement.
 

Toolkit for Disclosures of Ownership and Control The regulation at 42 CFR § 455.104 requires Medicaid providers (other than individual providers or groups of practitioners), fiscal agents, and managed care entities to disclose information on ownership and control.  The Affordable Care Act expanded this regulation to include greater scrutiny of managing employees of disclosing entities, collection of disclosures from managed care plans and capture of additional information on individuals and corporate entities.
Toolkit for Disclosures of Business Transactions The regulation at 42 CFR § 455.105 requires Medicaid providers to disclose information related to certain business transactions upon request of the state Medicaid agency or the Secretary of HHS.
Toolkit for Disclosures of Healthcare-Related Criminal Convictions The regulation at 42 CFR § 455.106 requires providers to disclosure the identity of any person who has ownership or control interest in the provider or who is an agent or managing employee of the provider and has been convicted of a criminal offense related to involvement in Medicare, Medicaid or Title XX programs.
Toolkit for Notifications to the HHS OIG The regulation at 42 CFR § 1002.3(b)(2) and (3) requires the state to notify HHS OIG of adverse actions taken against providers.  This includes actions taken against a provider for cause either to deny enrollment or to limit participation of an enrolled provider.  The toolkit helps address common issues for states regarding notifications to HHS OIG and provides examples of actions that would not need to be reported.
Toolkit for Federal Database Checks The regulations at 42 CFR 455.436 and 455.450 are part of the new provider screening and enrollment requirements under Section 6401 of the Affordable Care Act.  These regulations specify those providers (individuals and entities) and affiliated parties that must be screened to determine if they have been excluded or debarred from participating in Federal health programs and which databases must be checked.   The toolkit helps address common issues for states regarding exclusion searches and provides a number of links to additional guidance and websites.