There are some healthcare providers who are no longer welcome in Medicare and Medicaid. Patients, caregivers and taxpayers should know that unprecedented actions are being taken to make sure they don't participate in these federal programs.
Healthcare provider enrollment and screening rules are in place to prevent people who pose a threat to the safety of Medicare and Medicaid beneficiaries from entering the programs—along with the waste of millions in taxpayer dollars—all without interrupting patients' access to necessary care and services.
About 578,000 providers and suppliers are no longer allowed to bill Medicare and an additional 8,000 providers have been prevented from entering and participating in the program in the first place. As the largest payer of healthcare services, Medicare alone receives over 1 billion claims a year from about 1.6 million enrolled physicians and other providers. The Affordable Care Act made it possible for Medicare and Medicaid to raise the bar for provider participation in the programs.
Since 2011, these enrollment screening efforts have saved Medicare $2.4 billion.
Of course there's still a great deal to be done. As the CMS works to strengthen the program, we know there are other bad actors trying to abuse the system and potentially put patients at risk. Prior to the ACA, Medicare had few rules to screen enrolling providers and suppliers and remove violators. While the majority of healthcare providers and suppliers are conscientious in their care for patients and abide by payment regulations, a small segment bill the program for services never provided, charge more than they should for their services, or provide demonstrably unnecessary services that pose a threat to patient safety. The additional authority provided under the ACA has allowed the federal government to use new tools to safeguard patient lives and taxpayer dollars.
Many of the new tools are common sense, such as risk-based provider enrollment, which varies the level of enrollment screening based on the risk a given provider or supplier presents to beneficiaries and the program. The CMS now checks licensing status of all Medicare-enrolling providers and suppliers, as well as criminal records, and has implemented fingerprint-based background checks for providers and suppliers considered “high risk.”
We perform site visits to ensure qualifications and resources are in place for the healthcare services these providers are planning to deliver once enrolled. These checks are done on a continuing basis, in case provider or supplier information or qualifying status changes over time.
Doing this work has meant building all new systems and processes. The CMS now uses more than 300 state and federal databases to perform continuous licensing and background monitoring. We've conducted nearly 230,000 clinical location site visits and over 2,000 fingerprint checks since 2011. We also collaborate and communicate with states to ensure they have access to this important information and are making the same changes in their Medicaid systems.
The CMS' efforts do not stop at enrollment. We also work to ensure providers and suppliers who meet our enrollment standards continue to demonstrate compliance with rules and requirements and take action against those who abuse the program or provide unsafe care, including suspending payments or removing them from the program.
Safe, high-quality care has to be our priority—and we know this is a priority shared by the majority of physicians and healthcare professionals. The CMS is committed to using all available tools and authorities to thoughtfully, but purposefully, protect patients and sustain the Medicare and Medicaid programs. To build on these existing efforts, we recently announced new proposals aimed at closing loopholes that currently allow some abusive or fraudulent providers and suppliers to still enter the Medicare and Medicaid programs. These efforts include:
These proposals are open for public review and comment until April 25. We welcome feedback and will continue to work with stakeholders to implement a system that protects beneficiaries, taxpayers, healthcare providers and suppliers that are committed to patient safety and the true intent of our programs.
Dr. Shantanu Agrawal is director of the CMS' Center for Program Integrity.
