Comprehensive Medicaid Provider Screening is Imminent: Electronic Credentials Management Is Required

Through the Supreme Court's recent upholding of the Affordable Care Act (ACA), the healthcare industry received confirmation that nationwide expansion of healthcare coverage is on the horizon. This decision is unparalleled in its impact to the healthcare industry at large. A significant aspect of this legislation, Medicare and Medicaid fraud, waste and abuse (FWA) prevention via extended provider screening requirements must now be implemented across the US.  Perhaps the least controversial of the legislation requirements, many industry leaders believe that in 20 years, it is the FWA efforts that will have caused the most significant impact on the healthcare industry as a whole. Comprehensive Medicare and Medicaid provider screening is therefore of key interest to healthcare leaders focused on compliance and administrative efficiency.

CMS Rule 6028-F was released in February of 2011, which outlined (i) the new extensive provider screening requirements facing Medicare and State Medicaid agencies, (ii) implementation deadlines required and the (iii) application of the new, more rigorous screening standards to new Medicare/Medicaid providers by March, 2011 and all current Medicare/Medicaid providers as they re-enrolled starting in March, 2012. With ACA legislation facing so many legal challenges, however, and faced with the massive overhaul of existing screening procedures, many State Medicaid agencies opted to wait for the legal battles to cease before committing to the implementation of the new standards.

The Federal government recently extended the full implementation deadline for Medicare providers from March, 2012 to March, 2015. Unfortunately for State Medicaid agencies, no such extension was granted for Medicaid providers. Medicaid agencies that opted to wait on the ACA ruling prior to initiating screening changes are now facing the need for immediate expansion and extension of provider screening requirements which should have been in place, according to CMS Rule 6028-F for at least the last 6 months for applicable Medicaid providers. While Medicare has time to build in-house solutions and develop vendor partnerships to maintain compliance, for Medicaid agencies, these changes have to happen today. As such, many State Medicaid agencies are now eagerly seeking an immediate and compliant solution to this challenge.

The Electronic Credentials Management Solution
One of the key tenets of the new provider screening requirements is the continuous monitoring of provider credentials through monthly verification against key State and Federal databases in order to keep provider credentials accurate at all times. This kind of constant provider screening requires a dynamic, intelligent technology solution that is widely accessible and easily integrated with existing systems and across Medicaid departments. Luckily, with the advent of Web services and other software innovations, the area of provider screening/credentials management is quickly adapting to these new conditions. With real-time credentials information-rather than updates which can arrive months or even years following changes to a provider's credentials-Medicaid agencies can ensure patient safety, decrease liability, and proactively prevent FWA through automation and unparalleled data accuracy. Continuous monitoring of provider qualifications through Web-based provider data management allows immediate, automated notification of any discrepancy in provider information as compared against trusted primary sources (e.g., DEA, State License Boards, etc.)-and finally prepares Medicaid agencies to efficiently and inexpensively eliminate provider fraud in moments.

So what exactly is Web-based provider data management? Web-based provider data management generally involves one or more of the following attributes: (1) a provider portal allowing electronic submission of required provider information, (2) a centralized provider data repository accessible by all applicable Medicaid agency departments, (3) automated and continuous electronic verification of provider information against primary sources, and (4) integration of provider information to upstream and downstream systems. Through these tools and improved processes, efficiency and patient safety are simultaneously improved while compliance with CMS requirements is achieved.

Implementing Your Provider Screening Solution: Keys to Success
With a better understanding of what type of solution Medicaid agencies should target, the question now is how to choose the partner that will best combine immediate implementation, extensive subject matter expertise and adaptable technology solutions. Faced with this challenge, many Medicaid agencies are now finding that industry-leading CVOs with patented technology have proven to be a sound choice in this arena, with technology that is immediately available for implementation and services with well-documented results.

Once such a partner has been chosen, it's important to remember these basic guidelines for a successful and efficient implementation:
Leadership Support  Successful provider data management implementation is a commitment, and it only works if an agency's leadership fully embraces and endorses it. This can be easily exhibited through direct communication from leadership members to affected personnel describing the benefits and management support of the project. This support can also be demonstrated through milestone meetings and quick response to resource issues.
Education  Senior management must openly share the motives and benefits for making a change to the new processes and involve the contractor in demonstrating the new capabilities and advantages of the technology and outsourced services. 

Collaboration  Efficient project implementation depends on the agency and contractor engaging as partners and anticipating that some employees will feel threatened by change and will look for a scapegoat-usually the contractor. For this reason, it's important to keep lines of communication open with personnel and to respond quickly to dissent before it waylays the implementation process.

Standardization  Anticipation of the number of sub-processes involved in standardization is a key to success. Language changes for provider application consents and attestation forms, new types of reports, automatic notifications, etc. can result in significant project delay. These issues should be identified and dealt with at the outset to save time and reduce IT charges with your selected contractor. 

Conversion  In order to achieve complete centralization of provider data, there often needs to be a merger of multiple data sets into one. While this can be accomplished in a number of ways, a great deal of labor is necessary to create a master data file. There is also the issue of choosing the personnel who will perform the data clean-up. Failure to properly plan data clean-up will result in severe delays, errors and unhappy provider data management staff personnel who will tend to associate the new system with increased work and stress. By making the transition as easy on the primary users as possible, an agency will only increase internal support for the new provider data management solution and streamline the conversion process.

The Medicaid Provider Screening Requirement: Required Today
With expanded coverage upheld by the Supreme Court's recent decision, patient populations and corresponding healthcare provider populations will be growing exponentially over the next few years. Anticipating this flood of new patients and providers, Medicaid agencies must expand their provider screening requirements today to remain compliant and proactively guard against the possibility of resulting waves of fraudulent providers, wasteful procedures, and abusive practices. The key to immediate legal compliance and avoidance of possible FWA perils is the real-time knowledge of who Medicaid providers are and what they are qualified to do.

To begin the transition toward real-time, electronic provider credentials management as an industry standard, there needs to be a holistic view of the Medicaid provider data continuum. This view will feature Web-based provider communication platforms to ensure accuracy and completeness, automated and continuous primary source verification of all elements, Web Services integration between all stakeholders and a change of course in looking at provider credentials management as the foundation for quality care today. Through experienced partners with dynamic technology solutions, Medicaid can stick to both the spirit and letter of the law while keeping implementation time and costs at a minimum. Together, Medicaid agencies and their electronic credentials management vendor can change the paradigm of provider screening and simultaneously improve patient safety today.

Matthew Haddad is president and CEO of Medversant Technologies, LLC, and be contacted at As a healthcare industry consultant, Mr. Haddad has arranged financing and provided interim management to acute care facilities, skilled nursing facilities, psychiatric care facilities and assisted living centers. He is also a patent holder of Medversant's AutoVerifi" technology (US Patent No. 7,529,682 and 8,131,558).