Medicare background checks/fingerprinting

As part of the Affordable Care Act, Congress authorized background checks, including fingerprinting, for so-called “high risk” providers seeking to enroll in the Medicare program. Although the statute affords the Secretary of Health and Human Services (HHS) some discretion in defining ‘high risk” providers, the HHS department has generally classified a “high risk” provider as:

  • A durable medical equipment (DME) owner (minimum 5%)
  • Home Health Agency owner (minimum 5%)
  • Or any provider, including an individual practitioner who, due to some prior “bad” act warrants greater scrutiny

Recently, the College was contacted by a member about a newly hired nurse practitioner (NP) that was subjected to a full background check and fingerprinting. This was despite the fact the NP met NONE of the above criteria.

The practice contacted the Medicare contractor to determine why this was required. The contractor indicated the NP had been “randomly” chosen as part of a CMS effort to expand the program to individual clinicians regardless of whether they had a prior bad act. The practice was told Medicare would eventually require this of ALL physicians.

Given CMS had not announced any changes in the fingerprint/background check policy, the Advocacy Council looked into this matter further. Staff contacted the Medicare Director of Provider Enrollment for investigation and clarification.

In response to the College’s inquiry, we learned CMS has NOT expanded the fingerprint/background check program and there has been no authorization of “random” requirements for fingerprinting or background checks. This NP was inappropriately subjected to this process by the contractor.

Medicare expressed dismay that this had happened and appreciation to the College for bringing it to their attention. The College was told that corrective action would be taken “immediately” to ensure that ALL Medicare contractors understood and followed the requirements of the program.

To be clear, NO physician or other clinician should be subject to fingerprinting or a background check as a condition for enrolling in the Medicare program unless:

  1. The individual is a 5% or more owner in a DME supplier or Home Health Agency; OR
  2. Any of the following has occurred:
  • CMS has imposed a payment suspension on the individual within the last 10 years.
  • The individual has been excluded from Medicare by the Office of Inspector General.
  • The individual has had billing privileges revoked by CMS within the previous 10 years.
  • The individual has been excluded from any Federal Health Care program.
  • The individual has been subject to any final adverse action, in the previous 10 years.
  • The individual has been terminated or is otherwise precluded from billing Medicaid.
  • CMS has lifted a temporary moratorium for a particular provider or supplier type who then applies for enrollment at any time within 6 months from the date the moratorium was lifted.
Billing, Coding & Payments