Provider Notice issued 03/07/13

Category of Risk of the Vendor

To:​ Participating Medical Assistance Program Vendors and Applicants​
Date:​ March 07, 2013​
Re:​ Category of Risk of the Vendor​
  

As a result of Public Act 097-0689(pdf), referred to as the Save Medicaid Access and Resources Together (SMART) Act, enrollment of a vendor in the Medical Assistance Program (Medicaid) is conditional for one year (305 ILCS 5/5-5). During the period of conditional enrollment, the Illinois Department of Healthcare and Family Services (the department) may terminate the vendor's eligibility to participate in, or may disenroll the vendor from, the Medicaid program without cause. Such termination or disenrollment is not subject to the department's hearing process. However, a disenrolled vendor may reapply without penalty.

The department is authorized to limit the conditional enrollment period for vendors based upon the risk of fraud, waste, and abuse that is posed by the category of risk of the vendor. The department defines "high," "moderate," and "limited" vendor categories of risk as follows:

High Risk Vendor

  • Transportation (ambulance, medicar, hospital-based, taxicab/livery company, or nonregistered, but excluding private auto)
  • Durable medical equipment supplier
  • Home health

Conditional enrollment period: One year.

Moderate Risk Vendor

  • Hospice

  • Imaging center

  • Independent laboratory

  • Physical therapist

  • Alcohol and substance abuse provider

Conditional enrollment period: One year.

Limited Risk Vendor

  • All vendors that are not defined as either "high" or "moderate" risk

Conditional enrollment period: 9 months.   

Adjustment in the Category of Risk of a Vendor

 The department may adjust the category of risk level of a specific vendor from "high" or "moderate" risk to "low" risk if, within one year the date of submission of the vendor's application for enrollment in Medicaid, the vendor has been: 1) certified or accredited by Medicare, 2) issued a CLIA Certificate, or 3) enrolled in good standing in the Medicaid program of a state that borders Illinois.

The department will adjust the category of risk level of a specific vendor from "low" or "moderate" risk to "high" risk if any of the following occur:

  • The vendor* has been excluded, denied, suspended, terminated, debarred from, or otherwise sanctioned by Medicaid, Medicare, or any other federal or state healthcare program

  • The vendor* has a delinquent debt owed to the department

  • At any time during the last 10 years, the vendor* has:

    • Been subject to payment suspension by the department

    • Been precluded from billing Medicaid, Medicare, or any other federal or state healthcare program

    • Had billing privileges revoked by Medicare

    • Been subject to suspension or revocation of a license to provide healthcare by Illinois or any other state's professional licensing authority

    • Been subject to revocation or suspension by an accreditation organization, or

    • Been convicted of an offense defined in 305 ILCS 5/12-4.25(A-10)

Effective as of the date of this Provider Notice, during the conditional enrollment period, vendors are subject to enhanced department oversight, screening, and review based on the category of risk of the vendor:

Type of Oversight, Screening, and Review Limited Risk Vendor Moderate Risk Vendor High Risk Vendor
License/certification/authorization verification X X X
Database checks X X X
Prepayment audit review X X X
Audit X X X
Payment cap X X X
Payment suspension X X X
Unscheduled/unannounced site visit   X X
Criminal background check**     X
Financial background check**     X
Fingerprinting**     X

 

The department is authorized to use additional means of oversight, screening, and review, including as required by federal and state law.

Bradley K. Hart
Inspector General

* The vendor or a person with management responsibility for the vendor; an officer of the vendor; a person owning, either directly or indirectly, 5 percent or greater of the shares of stock or other evidences of ownership in a corporate vendor; an owner of a sole proprietorship that is a vendor; or a partner in a partnership that is a vendor.

** For all corporate vendors categorized as "high risk," screening activities apply to any person owning, either directly or indirectly, 5 percent or greater of the shares of stock or other evidences of ownership in the vendor. For transportation vendors categorized as "high risk," screening activities additionally apply to managers and dispatchers. For individual vendors categorized as "high risk," screening activities apply to the individual.