SF4311

1. Purpose
2. Strengthen oversight of medical assistance providers by expanding enrollment requirements, adding site visits, and increasing screening to prevent fraud, waste, and abuse.

3. Update funding and processes for provider screening and enforcement to align with federal rules and Minnesota needs.

4. Key provisions and what the bill does

5. Provider enrollment and site visits

   • Requires enrollment of all provider locations where direct services are provided.
   • Mandates site visits for enrollment, reenrollment, and revalidation of providers.
   • Establishes background checks (in line with 42 CFR 455 subpart 1 E) including fingerprint-based checks when required.
   • Allows background study to be satisfied by a prior fingerprint-based check that reviews specified databases.
   • Revalidates providers at least every five years (three years for certain types: personal care assistance CFSS providers, CFSS financial management providers, and EIDBI agencies; and more frequently for high-risk providers as designated by the commissioner).
   • Requires timely responses to enrollment information requests (60 days) and sets procedures for deficiencies and termination if not remedied.

6. Compliance and oversight

   • Creates mandatory compliance programs for certain provider types, including core CMS elements (policies, training, response to improper conduct, monitoring, and reporting).
   • Requires compliance officers for certain providers (e.g., providers licensed as home care or assisted living with specific designations) to oversee adherence to laws, prevent improper claims, train staff, and report overpayments.
   • Allows suspension of a provider’s ability to bill for noncompliance, with no right to an administrative appeal in some cases.
   • Authorizes unannounced CMS onsite inspections of provider locations before enrollment, reenrollment, and revalidation; requires disclosure of designated risk status in a public provider manual.
   • Enables withholding of payment for high-risk providers for 90 days after initial enrollment.
   • Allows revocation of enrollment for patterns of missing documentation or failure to provide access to requested documentation.
   • Adds conflict of interest and protection provisions to ensure providers with Medicare/Medicaid terminations in other states face enrollment actions in Minnesota (with certain pediatric-focused exemptions).

7. High-risk designation and criminal background checks

   • Designates some providers as moderate/high risk by CMS or the commissioner and requires consent to criminal background checks (including fingerprinting where required).

8. DMEPOS surety bond requirement

   • Requires durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) providers to obtain a surety bond as a condition of initial enrollment, reenrollment, reinstatement, or continued enrollment.
   • Bond amounts: initial 50,000; if Medicaid revenue in the prior year is up to 300,000, bond remains 50,000; if over 300,000, bond increases to 100,000.
   • Bond naming and recovery provisions: Minnesota DHS is the obligee; bond allows recovery of costs/fees; action to recover must be within six years of a final agency decision.
   • Certain providers are exempt from the bond (e.g., federally qualified health centers, home health agencies, Indian Health Service, pharmacies, rural health clinics).

9. Application fees and funding

   • Creates an application fee for enrollment to fund provider screening activities ( deposited in a provider screening account in the special revenue fund).
   • Initial fee schedule and CPI-based adjustments: base amount for 2013, with adjustments for 2014 and subsequent years; fees apply to initial enrollments, new practice locations, reenrollment, and revalidation as applicable.
   • Fees not charged to certain providers (e.g., those already enrolled in Medicare or enrolled in another state with documentation of payment, and some grouping/billing scenarios).
   • The provider screening account funds costs of screening activities described in the bill and related federal requirements.

10. Related enrollment conditions and protections

    • Enables denials or terminations for incomplete applications; 60-day response window; 30-day notice and a further 30-day extension to comply; 60-day notice to terminate if still noncompliant.
    • Electronic correspondence to providers (MNITS mailbox) for most notices, with exceptions for background studies.
    • Certain protections and exemptions when a provider has limited or pediatric-focused practices or when other statutory criteria apply.
    • The list of provider types designated limited/moderate/high-risk and the criteria are published in the Minnesota Health Care Program Provider Manual; these designations are not subject to typical administrative appeals.

11. Significant changes to existing law

12. Expands mandatory site visits to all enrolled medical assistance providers and requires revalidation on a defined schedule (five years generally, three years for specific provider types and high-risk categories).

13. Introduces formal, ongoing compliance programs and a designated compliance officer for many providers.

14. Tightens enforcement with pre-enrollment, reenrollment, and revalidation unannounced on-site inspections by CMS or its agents and state authorities.

15. Establishes a mandatory, ongoing background check framework (including fingerprinting where required) and explicit high-risk designations guiding oversight intensity.

16. Adds a new financial mechanism (provider screening fees) and a bonding requirement for DMEPOS suppliers to ensure financial accountability and fund screening activities.

17. Creates stronger billing suspensions and a tighter path to revocation for noncompliant providers, with limited or no administrative appeal in some cases.

18. Requires disclosures and compliance measures linked to federal CMS standards (42 CFR 455 and CMS core elements) and integrates these with Minnesota’s own provider oversight processes.

Relevant terms - medical assistance providers, provider enrollment, site visits, provider-controlled location, background study, fingerprint-based background check, 42 CFR 455 subpart 1 E, revalidation, high-risk, compliance officer, compliance program, CMS, Centers for Medicare and Medicaid Services, unannounced onsite inspections, MNITS, provider manual, provider screening account, application fee, DMEPOS, surety bond, obligee, suspension of billing, termination of enrollment, pattern of noncompliance, overpayment, recovery of overpayment, EIDBI, CFSS, CFSS provider agency, CFSS financial management provider, home care provider, licensed, residential care/assisted living, 245A/144A/144G, 245C, 256B.04, 42 CFR, medical assistance fraud waste abuse.