As of March 2024, over 67 million in the United States are Medicare beneficiaries. Medicare is the single largest payer for healthcare services in the United States. In FY2021, the Centers for Medicare and Medicaid Services (CMS) reported that Medicare processed more than 1.1 billion fee-for-service (FFS) claims from over 1.5 million healthcare providers, making over $424 billion in Medicare payments.

Physician groups bill Medicare over $6 billion annually, making Medicare-enrolled providers a driving force of revenue, especially as an aging population dependent on federally funded programs seeks care. CMS holds Medicare-enrolled providers to higher standards, and training requirements reflect some of the nuances in the CMS program. Here’s what you need to know.

Why Additional Training Is Required for Medicare-Enrolled Providers

Training helps providers understand and adhere to Medicare’s complex regulations and guidelines, essential for maintaining compliance. This includes understanding billing procedures, coding requirements, and coverage policies. Proper training reduces the risk of errors that could lead to claim denials, audits, or penalties.

Training also safeguards the integrity of the Medicare program by educating providers on the specifics of its rules, how to report compliance violations, and how to maintain standards. Training programs, such as those required for Medicare Advantage and Part D providers, educate providers on their obligations and the expected ethical standards. This comprehensive understanding helps prevent fraudulent activities and helps beneficiaries receive appropriate care.

Required Training For Medicare-Enrolled Providers

Medicare-enrolled provider training refers to the mandatory educational requirements that healthcare providers must complete to participate in the Medicare program and maintain compliance with federal regulations. This training typically includes several key components: 

General Compliance Training

General compliance training for Medicare-enrolled providers helps providers understand and adhere to Medicare regulations and guidelines. Key aspects of this training include:

1. Content: The training is required for anyone who provides health or administrative services to Medicare enrollees. It also addresses Medicare Parts C and D compliance requirements.
2. Objectives: The training covers how a compliance program operates and helps trainees recognize compliance program violations that should be reported.
3. Core Requirements: This course should consist of one lesson and a post-assessment. Successful completion requires completing the lesson and scoring 70 percent or higher on the post-assessment. The training covers the seven core compliance program requirements mandated by CMS, including written policies and procedures, designation of a compliance officer, effective training and education, and procedures for prompt response to compliance issues.
4. Attestation: Providers must complete training within 90 days of their hire date and annually thereafter.

Fraud, Waste, and Abuse (FWA) Training

Fraud, Waste, and Abuse (FWA) training is designed to help healthcare professionals detect, prevent, correct, and report fraudulent, wasteful, and abusive practices within the Medicare system. Key aspects of this training include:

1. Content: The training covers definitions of fraud, waste, and abuse, examples of FWA in healthcare, relevant laws and regulations, and methods to identify and report suspicious activities.
2. Objectives: Providers learn to recognize FWA, understand prevention methods, identify reporting processes, and recognize potential consequences and penalties associated with violations.
3. Legal Framework: The training covers key federal laws such as the False Claims Act, Anti-Kickback Statute, Stark Law, and Exclusion Statute.
4. Reporting Mechanisms: Providers are educated on reporting suspected FWA, including using compliance hotlines and whistleblower protections.
5. Consequences: The training outlines potential penalties for FWA violations, including civil monetary penalties, criminal charges, and exclusion from Medicare participation.

Model of Care (MOC) Training

Model of Care (MOC) training helps providers understand and effectively implement the care model for Special Needs Plans (SNPs) in Medicare Advantage. Key aspects include:

1. Purpose: To educate providers on the unique needs of SNP members and how to deliver coordinated, high-quality care through the MOC framework.
2. Content: Covers the four key elements of the MOC
   1. Description of the SNP population
   2. Care coordination processes
   3. Provider network
   4. Quality measurement and performance improvement
3. Frequency: Must be completed annually by providers serving SNP members.
4. Provider Responsibilities: Understanding their role in implementing the MOC, coordinating care, and contributing to quality goals.

Person-Centered Care Training

The Affordable Care Act of 2010 requires CMS to verify that nurse aides receive regular training on caring for residents with dementia and preventing abuse. CMS and subject matter experts created the Hand in Hand in-service training for nurse aides to meet this requirement.

1. 1. Purpose: The mission of the Hand in Hand training is to provide nursing homes with a high-quality training program that emphasizes person-centered care in the care of persons with dementia and the prevention of abuse.
   2. Content: The hand-in-hand training materials include an orientation guide and six one-hour video-based modules, each with an accompanying instructor guide. Though Hand in Hand is targeted at nurse aides, it may be valuable to all nursing home caregivers, administrative staff, and surveyors. The training covers:
      1. An Introduction for Facilitators and Administrators
      2. Module 1: Understanding the World of Dementia: The Person and the Disease
      3. Module 2: What is Abuse?
      4. Module 3: Being with a Person with Dementia: Listening and Speaking
      5. Module 4: Being with a Person with Dementia: Actions and Reactions
      6. Module 5: Preventing Abuse
      7. Module 6: Being with a Person with Dementia: Making a Difference
   3. Frequency: The training must be completed annually.
   4. Provider Responsibilities: Leadership of facilities serving persons with dementia is required to provide training to nurse aides.

Required Training for Medicaid-Enrolled Providers

Though this article discusses Medicare-enrolled provider training requirements, I want to discuss how Medicaid enrollment and training differ. Each state administers its own Medicaid program under federal guidelines, allowing states to implement additional or more stringent requirements for provider enrollment.

Your state’s Medicaid program might require specific training based on the plan in which providers are enrolled, the type of patient population they’re serving, their provider classification (inpatient, outpatient, etc.), and state regulations. For example, some states have training specifically for residential providers applying restraints and different training for non-residential providers applying restraints. Training can be very nuanced, and your state Medicaid agency will communicate the requirements using a memorandum of understanding (MOU).

Medicaid training requirements can even vary across the specific payment models within Medicaid. For instance, providers enrolled in Medicaid-managed care plans in some states may be required to complete cultural competency or implicit bias training. With such specific guidelines that can vary widely, most learning management systems (including MedTrainer) are not equipped to help research and identify your facility’s Medicaid training requirements. However, if you know and share the requirement, MedTrainer’s compliance experts can often identify existing courses that meet the need.

Use an LMS To Streamline Medicare-Enrolled Provider Training

Healthcare leaders can’t take chances when it comes to Medicare-enrolled provider training. One mistake can cost thousands of dollars — or millions. Organizations that choose to bill Medicare must get trained providers in front of patients as soon as possible to maximize reimbursements and deliver quality care.

A healthcare-specific learning management system can significantly aid Medicare-enrolled provider training in several ways:

1. Up-To-Date Courses: A healthcare LMS employs staff who stay on top of changing regulations and work directly with subject matter experts to maintain required training modules, including general compliance, FWA, and MOC training.
2. Automated Tracking and Reporting: The software can automatically track each provider’s completion of required courses. This helps organizations easily monitor which providers have completed their training and identify those who need reminders.
3. Customized Learning Paths: If your software offers personalized learning paths, you can group all CMS-required courses for Medicare-enrolled providers to complete.
4. Record Keeping: Compliance software maintains detailed training completion records, including dates and scores. This is crucial for meeting CMS requirements to retain training records for at least 10 years.
5. Reminders and Notifications: The software can send automated reminders to providers about upcoming or overdue training, helping them meet annual requirements promptly.
6. Reporting and Analytics: Compliance officers can generate reports on training completion rates, identify trends, and assess the effectiveness of training programs, allowing for continuous improvement.
7. Integration with Other Systems: Choose a comprehensive platform that includes incident reporting, credentialing, and other modules all in one natively-built platform. Also, look for integrations with HRIS to reduce manual data entry and errors.
8. Effectively Manage Medicare-Enrolled Provider Training: This service helps healthcare organizations adhere to CMS requirements and maintain a culture of compliance with a healthcare-specific LMS.

More than 15,000 healthcare organizations trust MedTrainer’s all-in-one healthcare compliance platform. With credentialing, compliance, and learning rolled into one system, we help you meet the next regulatory challenge or business opportunity. Contact MedTrainer to see how it can help.