At a Jan. 11 question-and-answer phone-in session to elaborate on laws enacted as part of the Deficit Reduction Act, CMS made several clarifications. Callers were informed that the law does not require providers to hold classes or conduct training for employees, contractors, and agents to educate them about fraud and abuse. The law, which was effective Jan. 1, simply requires providers to create and distribute to those individuals a policy that addresses detection of fraud and abuse and outlines their rights as whistleblowers. Many of the questions fielded during the session were about how providers should interpret “contractors and agents” and how the $5 million Medicaid threshold was defined. In answering, CMS emphasized that responses were informational only and should not be constituted as official policy.
In answer to specific questions about the $5 million threshold, CMS said that the law would apply to a healthcare system with three hospitals, for example--even if the hospitals did not individually receive $5 million in Medicaid reimbursement--as long as the aggregate amount to the health system totaled $5 million. CMS also said that the $5 million is calculated on the amount paid to a provider, not the amount billed.
Defining a contractual relationship was less clear-cut, however. Billing and coding vendors are contractors, said CMS, as are suppliers who provide any healthcare product or services used by Medicaid patients. But less clear was whether members of a hospital medical staff are considered contractors. CMS also couldn’t immediately answer whether health plans were required to send and enforce policies to thousands of contracted hospitals and physicians, or how contractors were supposed to comply with multiple sets of policies from their customers. One caller asked why, 11 days after the law took effect, there are so few answers on how to comply with the law. CMS answered that every provider is responsible for following the law in order to receive Medicaid reimbursement but that the agency will issue final guidance, taking the call-in questions into consideration.
