The OIG and Provider Enrollment

The core functions of the OIG’s Provider Enrollment Integrity Screenings (PEIS) team achieve the “prevention” portion of OIG’s mission by completing all federally and state-required screenings for providers seeking to enroll in an HHS health care program, primarily Medicaid or CHIP.

Providers seeking to enroll, re-enroll or be revalidated are required to be screened based on their assigned risk level as a prerequisite of participation in Texas HHS programs. The Centers for Medicare and Medicaid Services (CMS) assigns a categorical risk level to each provider type based on its potential for fraud, waste and abuse. The Health and Human Services Commission (HHSC) is permitted to assign a higher risk level than the federally defined category but is not allowed to assign a lower risk level. For Medicaid-only provider types, HHSC, in collaboration with the OIG, determines the categorical risk level. Failure to appropriately screen and enroll providers in compliance with federal program integrity requirements may result in audit findings and potential loss of federal funding for the State of Texas.

After an application has been submitted, processed by Texas Medicaid & Healthcare Partnership (TMHP), and determined to be complete, the application is routed to the OIG for screening. By statute, the OIG has 10 business days to complete screening activities. Based on the outcome of the OIG’s review, a recommendation is made regarding whether the provider should be allowed to enroll in the HHS program.

The OIG PEIS team works closely with the TMHP, OIG Chief Counsel, HHSC Medicaid CHIP Services (MCS), CMS, and a variety of other stakeholders in conducting this process.

Common Deficiencies Identified by PEIS

All enrollment applications must meet the definition of a “complete application” to be processed. The definition of a complete application is located in Texas Administrative Code (TAC) title 1, section 371.1(17), pertaining to definitions.

The most common deficiency identified by the PEIS team is missing or incomplete disclosures. When an application does not contain all of the required disclosures, the PEIS team will return the application to TMHP as incomplete, requesting that a deficiency notice be generated and sent to the provider to obtain the needed information. When this occurs, it has the potential to delay processing of the enrollment application by an additional 25 business days, not including the amount of time it takes for the provider to respond to the deficiency.

Additionally, a provider’s failure to disclose required information could constitute grounds for denial of the enrollment application or, if discovered after enrollment, subject the provider to overpayment recovery, termination or other administrative actions or sanctions.

Criminal History Disclosure

Apart from traffic violations, all convictions are required to be disclosed regardless of when the event occurred. Section 42 Code of Federal Regulations (CFR) 1001.2 and TAC title 1 section 371.1(18) define a conviction as:

• A judgment of conviction has been entered against an individual or entity by a federal, state or local court, regardless of whether:
  • There is a post-trial motion or an appeal pending, or
  • The judgment of conviction or other record relating to the criminal conduct has been expunged or otherwise removed;

  Providers need to be especially cognizant of the fact that first offender programs and deferred adjudications meet the definition of a conviction and are required to be disclosed, as are any convictions, no matter how old.

  The disclosure of criminal history in and of itself is not necessarily a bar to enrollment. When reviewing criminal history information, the PEIS team takes several factors into consideration before making a recommendation to approve or deny an application. Additional information on these considerations is located in TAC title 1, section 371.1011, pertaining to recommendation criteria.

  Disclosure of License Actions

  All actions taken against a professional health care license, disciplinary or non-disciplinary, are required to be disclosed in the enrollment application. This requirement applies to the enrolling provider and any individual or entity that is required to be disclosed in the enrollment application that has ever held a professional health care license, regardless of its current status.

  Disclosure of Managing Employees

  In addition to all owners, all individuals and entities that meet the definition of a managing employee are required to be disclosed in the enrollment application. Section 42 CFR 455.101 defines a managing employee as a general manager, business manager, administrator, director or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day-to-day operation of an institution, organization or agency.

  The HHSC Provider Enrollment and Management System (PEMS) provides further clarification in relation to the types of principals and subcontractors who meet the definition of a managing employee and are, therefore, required to be disclosed.

  Some examples of individuals that meet the definition of a managing employee include, but are not limited to:

  • Executive staff, such as president, vice president, CEO, CFO, COO, directors, board members, trustees, etc.
  • Director of nursing.
  • Alternate director of nursing.
  • Medical director.
  • Activities director.
  • Administrator.
  • Pharmacist in charge.

  Some examples of subcontractors that meet the definition of a managing employee include, but are not limited to:

  • An individual, agency, or organization to which a disclosing entity has contracted or delegated some of its management functions or responsibilities of providing all or part of the goods, services, work, materials required or medical care to its patients.
  • A management company that the enrolling provider has contracted with to perform any services related to the enrolling provider’s participation in HHS programs.
  • An individual, agency or organization with which a fiscal agent has entered into a contract, agreement, purchase order or lease (or leases of real property) to obtain space, supplies, equipment or services provided under the Medicaid agreement.

  How to Avoid Processing Delays

  The best way to avoid any delays in the processing of your enrollment application is to ensure that:

  • The application is complete and accurate.
  • The information in your Medicare enrollment record matches the information in your Medicaid enrollment application, if you are enrolled in Medicare.
  • All information on both your Medicare and Medicaid enrollment records is current.

  Additional Resources

  TMHP’s Provider Enrollment and Management System (PEMS) provides easy to follow step-by-step instructions on how to submit your enrollment application.

  TMHP’s Provider Enrollment Help page contains links to video tutorials and demonstrations, provider enrollment training modules, helpful guides, FAQ, and contact information for TMHP’s Provider Relations team if additional assistance is needed.