Healthcare, Medicaid and Background Checks

Beginning August 1st, any provider considered high risk for defrauding state Medicaid programs will be forced to undergo a criminal background check. The background check must include fingerprinting. The background checks will need to be completed by June 1st, 2016.

There will other changes as well. By March 2016, all of a state’s Medicaid and Children’s Health Insurance Program providers must be ranked as limited, moderate or high risk of defrauding the program. The Centers for Medicare & Medicaid Services sent a letter to providers last month, making them aware of the upcoming changes.

The ranking of the providers will be up to the discretion of the states. A background check would begin after a state Medicaid agency has been identified as “high risk”. Also, if Medicare deems a provider “high risk”, Medicaid will likely initiate a background check. The requirement to submit fingerprints would apply to the high risk provider. It would also apply to a five percent or more direct or indirect ownership in the provider. Seems a little complex, but this rule should keep things a little simpler.

However, there are issues that remain somewhat cloudy. In 2011, the Affordable Care Act published a final rule, stating that Medicaid agencies must establish risk levels for providers with an increased risk of fraud. Since the rule did not specify the criteria for each risk, it leaves states responsible to determine how a high risk provider is identified.

Understanding the importance of background checks is invaluable, and not just in the healthcare industry. The best hiring managers make comprehensive background checks a vital part of the screening and hiring process.