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 The continued participation of banned providers leaves state
Medicaid programs for the poor and disabled vulnerable to fraud,
waste and abuse, according to the study, which says the problem
reflects a struggle by states to communicate with one another.
The study, conducted by the U.S. Department of Health and Human
Services Office of the Inspector General (OIG), also found that
about half of the states were unable to terminate providers enrolled
in privately run Medicaid managed care programs. Some refuse to
terminate providers still licensed by a medical board, it found.
“If a provider has been terminated by a state, that is a red flag,
because it would indicate there was a problem either in billing or
the way they handle patients," said Deborah Cosimo, team leader for
the report. "Do states really want to trust beneficiary care to
someone who has problems like that?”
The report follows a Reuters investigation published in April that
found 1,800 providers banned by the federal Medicare program for the
elderly or a state’s Medicaid program were still able to bill
elsewhere in 2014. (Click http://www.reuters.com/investigates/special-report/usa-medicaid-fraud/
for the Reuters special report)
Under the Affordable Care Act, which was implemented in 2011, all
states are required to terminate providers banned by another state
for reasons related to fraud, integrity or quality. Prior to 2011, a
provider terminated in one state could enroll in another state’s
program.
But the Centers for Medicare and Medicaid Services (CMS), the agency
that administers Medicare, does not require states to report
terminated providers to a federal database that shares the
information and would not say if it planned to do so, the auditor
wrote.
“The government hasn’t done what it is expected to do to keep
providers who shouldn’t be in the program out of the program,” said
Kevin Golladay, OIG regional inspector general for Region VI.
Reuters obtained a copy of the report in advance of its release. OIG
was working on the report before Reuters published its investigation
in April.
The auditor examined 2,539 providers terminated by a state in 2011
and found 295, or 12 percent, still participated in another state’s
Medicaid programs. It found Medicaid programs paid $7.4 million to
94 providers for services performed after the providers were
terminated.
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The auditor identified only individual providers, not companies. New
Mexico had the most terminated providers still participating in its
program, with 33, and Massachusetts had the second-most, with 30.
California paid terminated providers the most, $1.7 million,
followed by Mississippi, $1.2 million, and Wyoming, $919,000.
One state Medicaid program paid a single provider more than $1
million for services performed after the provider’s termination.
The latest report may underestimate the number of providers who
continue to participate in Medicaid after termination and the amount
they were paid due to poor record keeping by the states, the auditor
wrote.
Seventy-five percent of the terminated providers still approved to
bill in other states were doctors and 11 percent were mental health
workers.
CMS, in a June 19 letter to OIG, agreed with the report’s
recommendation that it work with states to develop uniform language
to identify providers terminated for cause.
It said it also supports a requirement for states to screen
providers in privately run managed care programs in Medicaid and a
recommendation that the CMS tell states to terminate providers
banned by other states even if the provider still has a medical
license.
(Reporting by M.B. Pell; Editing by Frank McGurty and Dan Grebler)
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