Medicare medicaid and chip program integrity

HHS based on age, disability, terminal illness, or an individual‟s quality of life preference.
Medicare, Medicaid, and CHIP Program Integrity Provisions: The Secretary will establish
procedures to screen providers and suppliers participating in Medicare, Medicaid, and CHIP.
Providers and suppliers enrolling or re-enrolling will be subject to new requirements including a fee,
disclosure of current or previous affiliations with any provider or supplier that has uncollected debt,
has had their payments suspended, has been excluded from participating in a Federal health care
program, or has had their billing privileges revoked. The Secretary is authorized to deny enrollment in
these programs if these affiliations pose an undue risk.
Enhanced Medicare and Medicaid Program Integrity Provisions: CMS will include in the
integrated data repository (IDR) claims and payment data from Medicare (Parts A, B, C, and D),
Medicaid, CHIP, health-related programs administered by the Departments of Veterans Affairs (VA)
and Defense (DOD), the Social Security Administration, and the Indian Health Service (IHS). New
penalties will exclude individuals who order or prescribe an item or service, make false statements on
applications or contracts to participate in a Federal health care program, or who know of an
overpayment and do not return the overpayment. Each violation would be subject to a fine of up to
$50,000. The Secretary will take into account the volume of billing for a DME supplier or home
health agency when determining the size of a surety bond. The Secretary may suspend payments to a

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provider or supplier pending a fraud investigation. Health Care Fraud and Abuse Control (HCFAC)
funding will be increased by $10 million each year for fiscal years 2011 through 2020. The Secretary
will establish a national health care fraud and abuse data collection program for reporting adverse
actions taken against health care providers, suppliers, and practitioners, and submit information on the
actions to the National Practitioner Data Bank (NPDB). The Secretary will have the authority to
disenroll a Medicare enrolled physician or supplier who fails to maintain and provide access to written
orders or requests for payment for durable medical equipment (DME), certification for home health
services, or referrals for other items and services. The HHS Secretary will expand the number of areas
to be included in round two of the DME competitive bidding program from 79 of the largest
metropolitan statistical areas (MSAs) to 100 of the largest MSAs, and to use competitively bid prices
in all areas by 2016.
Additional Medicaid Program Integrity Provisions: States must terminate individuals or entities
from their Medicaid programs if the individuals or entities were terminated from Medicare or another
state‟s Medicaid program. Medicaid agencies must exclude individuals or entities from participating in
Medicaid for a specified period of time if the entity or individual owns, controls, or manages an entity
that: (1) has failed to repay overpayments; (2) is suspended, excluded, or terminated from participation