Senator Charles Grassley (R-IA), the co-author of the Sunshine Act, recently sent letters to all 50 states this week asking how they sanction doctors in their state health programs and whether they alert the federal government when they do. The letters cited examples from ProPublica’s reporting on its new Prescriber Checkup campaign, which identified doctors who had been kicked out of state Medicaid programs, but were still able to continue prescribing drugs to patients under Medicare.
Grassley expressed his concern that States were not communicating with Medicare or CMS about state or Medicaid related violations. As a result, patients may be exposed to unsafe medical treatment and millions of tax payer dollars may be wasted on fraudulent, abusive, and unreliable providers.
In his letter, Grassley explained that by statute (citing a recently enacted regulation implementing a new section of the Affordable Care Act), Medicare must terminate any individual physician or entity from its rolls if that provider was terminated under any State’s Medicaid program. However, the requirement to terminate only applies if the provider, supplier, or individual was terminated or had their billing privileges revoked “for cause. Accordingly, any Medicaid provider terminated “without cause” will not be mandatorily removed from Medicare.
States have broad discretion in terminating providers and may do so both for and without cause. Unfortunately, this flexibility means that States may bar doctors from State Medicaid programs and state medical boards may even censure providers because of fraudulent activity without reporting that the action was taken “for cause.” As a result, a “without cause” termination enables duplicitous and untrustworthy providers to continue to draw from Medicare, wasting tax dollars and putting patients at risk, Grassley wrote.
After citing the various incidents ProPublica found in its initial Prescriber Checkup reporting, Senator Grassley asked that the States submit answers to the following questions by July 15, 2013.
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Please provide your definition of both (i) for cause and (ii) without cause termination.
- Please provide any factors you consider when determining without cause provider termination over for cause, including how much notice you give the provider
- Is termination from Medicare a factor in your termination considerations?
- Please provide the ten (10) most recent physicians, including their Medicare provider numbers, who were terminated for cause, as well as the allegations against and detailed reasoning for their termination.
- Please provide the ten (10) most recent physicians, including their Medicare provider numbers, who were terminated without cause, as well as the allegations against and detailed reasoning for their termination. Please exclude those physicians who were terminated without cause due to inactivity within the program.
- Does the Medicaid program reimburse for prescriptions that are issued by a provider that has been terminated?
- Once you have terminated a provider from Medicaid, do you notify the Centers for Medicare and Medicaid Services (“CMS”)? If yes:
- Please list the last five (5) providers, including Medicare provider numbers, you have transmitted to CMS.
- How many providers has CMS terminated from Medicare due to your notifications? Please list each of these providers, including their Medicare provider number.
- Please describe the manner in which you notify CMS.
- What information do you include in your notification?
If not, why not?