Nearly 300 providers who were terminated for cause from one state in 2011 continued billing Medicaid in other states for as many as three years, according to a report from the Office of Inspector General (OIG). Those 300 physicians represented 12 percent of providers studied by the watchdog agency.
Provisions within the Affordable Care Act require all states to terminate a provider's participation in Medicaid if that provider is terminated for cause in another state. However, the OIG found that states struggle to comply with the health law's mandate because of they lack a "comprehensive data source" to easily identify for cause terminations from state to state.
Additionally, some states do not enroll providers in Medicaid managed care networks, making it difficult to track actions taken against providers, or even establish baseline data on physicians who are billing Medicaid.
Of the 295 providers identified by the OIG, 94 received $7.4 million from state Medicaid programs for services performed after they were terminated in another state. One of those providers received more than $1 million in reimbursement.
The report builds on a March 2014 report from the OIG in which the agency called on the Centers for Medicare & Medicaid Services (CMS) to make terminated provider data more accessible between states. The latest OIG report reiterated those recommendations, adding that CMS should work with states to develop uniform terminology for provider terminations, require states to enroll all providers in Medicaid managed care, and provide guidance to clarify that termination is not contingent upon the provider's active licensure status. CMS concurred with all three recommendations.
The OIG is not the only agency to address Medicaid fraud and abuse concerns surrounding barred or terminated physicians. Last week, a report from the Government Accountability Office (GAO) reiterated key concerns surrounding ineligible providers, and pointed to Medicaid managed care plans as a target for overpayments. In June, a GAO senior official told a Congressional subcommittee that four states paid $2.8 million to approximately 90 providers with a revoked medical license.
- read the OIG report
OIG: Beef up terminated provider data
Improper payments among the four key issues facing Medicaid
GAO to Congress: CMS needs to do more to prevent Medicaid fraud
GAO: Require states to show cost benefits of anti-fraud systems