Thousands of doctors that had their Medicare or Medicaid billing privileges revoked last year were still able to bill federal programs, according to a special report by Reuters. Data collected by the news outlet showed more than one in five physicians barred from Medicare or state Medicaid programs submitted claims in another state.
By analyzing records obtained from every state, the District of Columbia, and the Centers for Medicare & Medicaid Services (CMS), Reuters identified 1,800 physicians that were prohibited from billing Medicare or state Medicaid for "fraud, integrity, or quality" reasons, but were still able to submit claims in a different state. All told, CMS paid at least $79 million to 269 of those providers in 32 states and DC.
However, the report also indicated that those numbers were likely a significant underestimation of the actual value because of insufficient state and federal data. In reality, the true cost of banned physicians billing federal health programs could be hundreds of millions of dollars.
This is due in large part to "missing or erroneous data," according to Reuters, and because state laws vary from the regulations that are outlined in the Affordable Care Act. For example, physicians that are terminated from Medicare "for cause" are required to be terminated in all state programs. However, the definition of "for cause" varies from state to state. Additionally, data-sharing capabilities outlined in the ACA have hit numerous roadblocks preventing states from accessing updated physician information.
As a result of the article, 17 states have launched investigations in an attempt to collect improperly paid claims to physicians that were revoked in other states. Minnesota is looking to get back $548,000 from five providers and Nevada is trying to reclaim $250,000, according to Reuters.
Although the Reuters report further quantifies the problem, the issue of paying banned physicians is not new. Last year, a House Committee grilled former CMS Administrator Marilyn Tavenner about how CMS screens providers before issuing payments. Then there's the infamous case of Florence Bikundi, a home healthcare owner that fraudulently billed Medicaid $78 million despite the fact that she was barred from Medicare since 2007.
- read the Reuters article