About 12% of providers kicked out of their state Medicaid programs for fraud, integrity or quality issues are still participating in other states' Medicaid programs, according to a report released Tuesday by HHS' Office of Inspector General.
According to the report, 295 providers across the country who were terminated from their states' Medicaid programs for cause in 2011 were still billing other states' Medicaid programs in 2014. Under the Affordable Care Act, states are supposed to pull providers' from their Medicaid rolls if they've already been removed from another state's program for fraud, integrity or quality problems.
“The continued participation of these providers after their terminations for cause from other State programs presents a vulnerability to Medicaid,” according to the OIG report.
Of those 295 providers, 94 received $7.4 million from Medicaid after they had already been yanked from their original states' programs. State agencies said the other 201 providers never received Medicaid dollars. Still, the OIG report said it's “concerning” that those providers were allowed to continue treating Medicaid beneficiaries.
Fifteen of the providers received Medicaid payments of $100,000 or more, and one got more than $1 million.
The OIG blamed the issue on the lack of comprehensive data sources available to states that would allow them to identify all terminations for cause.
The OIG also noted that 25 of the 41 states that use managed care to deliver Medicaid services did not require providers participating through managed care to be enrolled with the state Medicaid agency. States cannot terminate providers who are not directly enrolled, the OIG said.
The OIG is recommending the CMS require state Medicaid agencies to report all terminations for cause. It's also recommending the CMS require state Medicaid programs to enroll providers participating in Medicaid managed care and work with states to create common terminology to help states identify providers terminated for cause.
In its response to the report, the CMS agreed with the recommendations and noted it has already taken a number of steps to fix the problem.
For example, the CMS published a notice of proposed rulemaking in June that would require state Medicaid programs to enroll providers participating in Medicaid managed care.
The CMS also, last year, implemented a new Medicaid termination system under which states submit terminations to the CMS, which then reviews them and enters those that are for cause into a database accessible to state Medicaid programs.
“The CMS is committed to improving program integrity efforts in the Medicaid program,” CMS Acting Administrator Andrew Slavitt wrote in the response.
The National Association of Medicaid Directors was not able to immediately comment on the report Wednesday morning, but the organization also recommended last year, in a letter to the CMS and HHS' Center for Program Integrity, that the CMS clarify differences in terminology about provider terminations. The association also recommended that the CMS share information about terminated Medicaid providers through a centralized system.
Patrick Burns, co-director of the Taxpayers Against Fraud Education Fund, said the OIG report raises the important question of how to stop excluded providers from staying in the system. But he said it's difficult to know exactly how big a problem it is without further disaggregating the numbers.
Still, he said, “We want proof the person who's standing before you, who's Dr.Jones is, in fact, Dr. Jones, and that Dr. Jones is not really a guy excluded in New Mexico or Florida or California."
Clinton Mikel, a partner with The Health Law Partners in Southfield, Mich., which represents providers among others, said the report seems to be part of a larger trend of the government more aggressively trying to police its program enrollments. The CMS issued a rule in December saying that it would deny or revoke Medicare billing privileges from providers who routinely bill for services that don't meet program requirements.
Mikel believes the crackdown is driven by the government's desire to recoup more cash lost through fraud.
“We're seeing a lot of action from the CMS trying to essentially clean up the fact that they had not previously, extensively policed their provider enrollment,” Mikel said. “I think this is merely a part of a larger pattern.”