The Office of Inspector General of the U.S. Department of Health and Human Services recently released a report seeking to find out the extent to which individual providers who are terminated for cause from one or more State Medicaid programs continue participating in Medicaid in other States. OIG also looked into the amount Medicaid paid to such providers, if any, for services performed after termination. The agency then identified a number of challenges that states face in ensuring that terminated providers do not continue to participate in other state Medicaid programs.
View OIG’s full report here.
OIG noted that before the passage of the Patient Protection and Affordable Care Act (ACA), if a State terminated the participation of a provider from its Medicaid program, the provider could potentially participate in another State’s Medicaid program, leaving the second State’s program vulnerable to the same issues of fraud and waste that got the provider terminated in the first place. To prevent this from happening, the ACA requires that each State terminate a provider’s participation in the State Medicaid program if that provider is terminated for cause (i.e., for reasons of fraud, integrity, or quality) from another State Medicaid program.
OIG outlines how this would work:
In practical terms, after a State terminates a provider for cause, other States’ implementation of section 6501 of the ACA involves three steps: learning, identifying, and acting. First, a State agency must learn about providers who were terminated for cause from Medicare or other State Medicaid or CHIP programs. Second, the agency must identify whether any of those terminated providers are participating in the State’s Medicaid program, taking steps to verify a provider’s identity, if it is in question. Third, the agency must act appropriately to terminate the provider’s participation in its own State Medicaid program.
However, the report stated that 295 providers terminated from Medicaid for fraud, misuse, or abuse in 2011 (after the ACA came into effect) continued to participate in other states’ programs. OIG found that 94 of these providers received payments from state Medicaid programs, totaling $7.4 million.
While OIG identified these issues, they noted that states face some considerable challenges in ensuring banned providers do not continue participating in other Medicaid programs. These include:
- The lack of a comprehensive centralized data source that identifies providers terminated for cause, which creates challenges for State agencies seeking to learn about such providers.
- Lack of uniform terminology in existing data sources regarding the reasons for provider terminations, which can create challenges in differentiating provider termination status.
- State Medicaid agencies that do not enroll all providers can face challenges in identifying their managed care providers and terminating Medicaid participation
- The active status of a provider’s professional license can cause misunderstanding for some State Medicaid agency staff n making their decisions about whether to terminate a provider.
This report followed an OIG inquiry last year. In March 2014, the agency recommended that CMS require State Medicaid agencies to report all for cause terminations. “We reiterate this prior recommendation as we found the lack of a comprehensive data source of providers terminated for cause creates a challenge for State Medicaid agencies,” stated OIG.
To address the remaining issues identified in this report, OIG recommend that CMS:
- (1) work with States to develop uniform terminology to clearly denote for cause terminations,
- (2) require that State Medicaid programs enroll all providers participating in Medicaid managed care, and
- (3) furnish guidance to State agencies that termination is not contingent upon the provider’s active licensure status. CMS concurred with the recommendations, OIG noted.