What is a non-institutional Medicaid provider?
As the name implies, non-institutional providers refer to those providers that are not licensed as institutional providers, which would include hospitals and facilities such as nursing homes, assisted living facilities, and emergency medical transportation providers. As a general rule, non-institutional providers are those that provide medical care to recipients. More specifically, non-institutional providers are: physicians, physician groups , and allied health professionals; clinics; home health agencies; durable medical equipment companies; medical suppliers; pharmacies; laboratories; radiology facilities; independent transportation providers; hospitals; rural health clinics; and independent psychological examiners. Depending on the state and the services the provider wishes to provide Medicaid recipients, at some point during the provider participation process, some or all of these providers may have to have executed a non-institutional Medicaid provider agreement to participate in Medicaid. The agreement reiterates and incorporates the provider qualifications, responsibilities, and all terms and conditions for participation in the Medicaid program.
Essential terms of a Medicaid provider agreement
The essential elements of a non-institutional Medicaid provider agreement include that the provider, in exchange for conditions, provides services to Medicaid recipients. Additionally, the provider agrees to the terms in the agreement and shall be bound by it. Significantly, a proper and complete billing form will be submitted for payment. Further, there are other terms which all providers must accept: to accept Medicaid’s payment as payment in full, with full payment due if the established reimbursement policy is not followed; an agreement to file a prompt and proper claim for services rendered; an acknowledgment of the right of the state to recover overpayments from future claims; and a requirement to promptly report any change affecting eligibility, which includes changes in address, services offered, ownership, or controlling interests and criminal convictions (regardless of any related conviction record restrictions).
Also, Non-Institutional Medicaid providers are required to retain financial, medical, and temperature records for five years, and submit them promptly upon the request of the state. They must also inform the state of any legal issues or sanctions against the provider within five days. If there is a relationship (defined as 5% or more) between the provider and the spouse, parent, child or sibling of a Provider or of a person with a 5% or greater ownership interest in a directly or indirectly related organization, which entity is a provider, staff-member, administrator or manager (or otherwise has a material involvement in the provision of service or the operation or management of the facility), the entity will also be deemed a party to the agreement.
Eligibility requirements for non-institutional providers
Non-Institutional providers are required to meet minimum criteria for licensure or certification, credentialing, professional qualifications, and ability to provide care in order to qualify for entry into non-institutional provider agreements with Medicaid agencies. For those providers who are required to be licensed or certified in their state, the licensing or certification requirement must be satisfied as a condition of entering into and continuing to participate in the Medicaid program. This licensure or certification requirement varies by provider type. Other criteria include:
• Evidence, satisfactory to the State, of an adequate source of financial support to ensure that the provider can meet obligations, including, as applicable, the costs of complying with the provider agreement, the costs of operations, and the costs of furnishing services to recipients. Individuals must not have a felony or fraud conviction and must not have been terminated from a provider agreement.
• Individuals must not have been disqualified on the basis of professional competence, unprofessional conduct, or professional treatment violations, or denied a health care or professional license by a state agency.
• Apart from limited exceptions, the provider must document that it has no liability against the United States or State of Florida for overpayment of Medicaid funds.
• Providers may not have a pattern or practice of requesting or providing medically unnecessary services or otherwise defrauding the Medicaid program, for failing to disclose or report certain related-entity relationships, and must disclose any current or prior ownership or controlling interest in other Medicaid-participating entities.
How to enroll in the Medicaid program as a non-institutional provider
If you are a non-institutional Medicaid provider interested in participating in the Medicaid program, you must first enroll in Medicaid. The enrollment process requires you to complete a provider application and submit it to your state Medicaid agency. Your state Medicaid agency will then conduct a screening process as well as a criminal background check. The agency will approve or deny your enrollment based on the results of the screening and background checks. The agency may also enroll you without your submitting a provider application if you hold a current, unencumbered license to practice in the state or if you have not yet received a federal employer identification number but you provide services in anticipation of receiving one. These involvement requirements may vary by state.
The Medicaid provider enrollment application may be submitted directly via state Medicaid agency applications that are available online or through paper applications. Alternatively, you may have your Medicare provider enrollment application filed with the Centers for Medicare and Medicaid Services (CMS) through an Envoy certifying organization. Envoy is CMS’s electronic provider enrollment application. By using Envoy rather than the online or paper application available through state Medicaid agencies, you would file only one application for both the Medicare and Medicaid programs and receive one audit history for both programs.
Upon submitting your enrollment application, it usually takes between 30 days and nine months to receive approval. In some states, the average turnaround time is four to eight weeks. If you are denied Medicaid provider enrollment, you are able to seek a hearing regarding the agency’s decision within 33 months of its action.
Medicaid has several different types of providers, such as:
In addition, Medicaid allows for participation from other categories as well.
Common challenges for non-institutional providers in a Medicaid provider agreement
Challenges Faced by Non-Institutional Medicaid Provider Agreements
In addition to the fact that non-institutional Medicaid services, and the daily operations of a non-institutional Medicaid providers, are heavily regulated, non-institutional Medicaid providers often encounter situations that create significant challenges to their providers. Some of these issues are unique to a particular state or a particular line of business (for example home health, personal care services, durable medical equipment). However, some challenges are prominent throughout the United States.
Two (2) of the most commonly cited challenges faced by non-institutional Medicaid providers relate to:
These challenges can have serious financial implications for non-institutional Medicaid providers . Namely, they can lead to unpaid bills or delays in payment, both of which impact cash flow. Further, a non-institutional Medicaid provider not willing or able to participate in the Medicaid program could be limited to providing services only to a subset of patients (those with private/commercial insurance), which in turn could create administrative challenges and lessen cash flow. As such, it is important for non-institutional Medicaid providers to know of the potential challenges, so that he or she may have procedures in place in order to be properly prepared should such challenges arise. In fact, as explained in more detail below, there are certain activities a non-institutional Medicaid provider can undertake to better position him or herself should a challenge arise.
Amendments and updates of a Medicaid provider agreement for non-institutional providers
Medicaid agreement language can vary based on the services the provider is providing. Most providers are aware of the basic Medicaid provider agreement contained in long-term care provider contracts. What they may not be familiar with are the other provider agreements that exist for non-institutional providers. For the past several years, Medicaid has been revisiting the language in most of the non-institutional provider agreements, primarily those agreements that do not include an attached provider manual. The reason for the change is that the Medicaid provider audits highlighted certain requirements that were omitted from the non-institutional provider agreements that are required for compliance. The new agreements contain additional and more specific language in the agreement to clarify requirements that must be followed by all providers.
For example, providers are now required to comply with the licensure requirement in the agreement. Before, it was only the provider’s responsibility to comply with the licensure requirements set forth by the Louisiana Department of Health (as stated in the provider manual) when in fact that was also a requirement in the traditional provider agreement that is not contained in the provider manual. In a typical provider agreement, the following is listed: "Provider certifies that it holds all Louisiana state and local permits or other authorizations (including, but not limited to, licenses, permits, registration, etc.) necessary to provide the services and goods defined herein. Provider shall maintain such licenses throughout the term of this Agreement."
Some of the other changes included the recoupment language and more explanation as to what acts will cause the immediate suspension of payments and termination from the program. The termination clause was also expanded to show that provider will be terminated for "committing fraud or abuse" and will have to repay any overpayment that was received as a result of the provider’s fraud or abuse. That is true for all providers, not just those that service the aged, blind, and disabled. Other standard provisions were added to the agreements, including the following: Physics and Speech and Hearing clinics will now require a NPI number and those clinics must update the Division of Health Standards and Certification Board and become accredited. Additionally, Medicaid managed care agreements (Part C) must be executed before a provider/facility may be eligible for Medicaid reimbursement at Part C rates.
As a result of these changes the Board of Pharmacy and the following non-institutional provider agreements are yet to be revised as of today: With the expansion of Medicaid through the expansion population (Medicaid Expansion), the addition of non-institutional provider agreements is likely going to increase dramatically. The Department has always maintained that the provider agreement language from these agreements will continue to change as the Department sees fit. It is important to remain on the lookout for these changes as they may impact your practice and how you bill various services to Medicaid.
The future of a Medicaid provider agreement for non-institutional providers
The trend towards more comprehensive and user-friendly non-institutional Medicaid provider agreements is likely to continue in the future. State Medicaid agencies may adopt policies that further prioritize the provision of care in home- and community-based settings, in line with national trends towards "aging-in-place" and promoting community living. The recent case law on reasonable assurance mandates may make many state Medicaid agencies review their non-institutional provider agreements to ensure that they are providing for adequate notice and opportunity to be heard to providers who may be terminated from the program or whose provider agreement is not renewed .
Technology will also play a role in the future of non-institutional Medicaid provider agreements. Several common devices used by non-institutional Medicaid providers, such as remote patient monitoring tools, have emerged in the past few years and may become more ubiquitous in the future. State Medicaid agencies may permit or encourage providers to use these tools to provide care more efficiently, assist providers in better utilizing Medicaid’s telehealth benefit, and otherwise help providers better serve their Medicaid patient populations.