Hospital Credentialing to Include Data Screening of Terminated Providers

Emily Berry, for HealthLeaders Media , October 8, 2010

If you’ve been wondering how healthcare reform will affect your hospital’s credentialing process, part of the answer may lie in new CMS regulations about terminated providers.

Specifically, the Patient Protection and Affordable Care Act of 2010 requires:

  • CMS to establish a process to make available to state Medicaid and Children’s Health Insurance Program (CHIP) agencies certain information on Medicare providers and suppliers that are terminated from participating in the Medicare program or CHIP
  • States to terminate any Medicaid provider that has been terminated from participation in Medicare or another state Medicaid program

The deadline for these changes is January 1, 2011.

Credentialing professionals typically check to see if a practitioner has been excluded from Medicare and Medicaid, but not if he or she has been terminated. However, whether terminated or excluded, the bottom line for hospitals is the same: it can’t collect payments on services that provider performed for Medicare and Medicaid patients.

 “Clearly, Congress decided there was a need to strengthen our screening of providers that come into and participate in the Medicaid program,” says Angela Brice-Smith, director of the Medicaid Integrity Group at CMS. “If you look at all the federal health programs, we should all be doing similar things in terms of making sure we have better-performing providers in the programs serving our beneficiaries.”


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2 comments on "Hospital Credentialing to Include Data Screening of Terminated Providers"

Jeannie Burton (10/14/2010 at 4:36 PM)
If CMS reports terminated providers via NPDB, because hospitals are not allowed to query HIPDB, then there shouldn't be a reason to establish yet another database.

Paula Thibodeau (10/14/2010 at 3:57 PM)
There already is a national database that could be used and that managed care organizations already query. If CMS simply reported all terminations to the HIPDB it would avoid the cost to [INVALID] and maintain another database. One problem, currently hospitals are not required to query the HIPDB. They do query the NPDB so this seems a minor issue to also require a HIPDB query.




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