Report: Fragmented databases hinder Medicaid provider screening

State agencies and insurers that offer Medicaid managed care plans are forced to pull from nearly two dozen different databases spread across 15 federal agencies in an attempt to screen providers, according to a report from the Government Accountability Office (GAO).

A review of two states and 16 health plans revealed "fragmented" and "disparate" databases that impede the ability to properly screen providers. Many of the databases accessed by state officials and health plans were not recognized by the Centers for Medicare & Medicaid Services (CMS), leading the GAO to recommend the agency consider other sources of information that could be used to screen providers.

"The difficulties states and plans experienced accessing databases and confirming matches could result in provider screening efforts that do not ensure that ineligible providers are accurately and consistently identified," the report stated.

Although CMS has encouraged states to share provider data through the Medicaid provider termination notification system, participation is inconsistent, and Medicaid managed care plans are not included in the database. Ten states reviewed by the GAO made provider ineligibility data available online, but location and content varied widely. The GAO recommended CMS provide states with best practices for sharing provider screening data.

In a previous report, the GAO found Medicaid made payments to 90 ineligible providers in 2011, totaling $2.8 million. Although CMS urged states to use Medicare's Provider Enrollment, Chain and Ownership System, many have said screening is hindered by limited access. With Medicaid's improper payment rate expected to rise above 11 percent in 2016, some organizations have said eliminating improper payments is critical to the financial sustainability of the program.

To learn more:
- read the GAO report

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