Twenty-three states reported allowing unenrolled providers to serve Medicaid beneficiaries
- Collection:
- Health Policy and Services Research
- Series Title(s):
- Report in brief (United States. Department of Health and Human Services. Office of Inspector General)
- Contributor(s):
- United States. Department of Health and Human Services. Office of Inspector General. Office of Evaluation and Inspections. issuing body.
- Publication:
- [Washington, D.C.] : U.S. Department of Health and Human Services, Office of Inspector General, March 2020
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Contract Services -- legislation & jurisprudence Government Regulation Managed Care Programs Medicaid -- legislation & jurisprudence United States United States. Department of Health and Human Services
- Genre(s):
- Technical Report
- Abstract:
- Why OIG Did This Review. An effective provider enrollment process plays a vital role in safeguarding Medicaid from fraudulent and abusive providers. To strengthen Medicaid provider enrollment, the Cures Act stipulated that States must require all Medicaid providers—both those in Medicaid FFS and Medicaid managed care—to enroll with their respective State Medicaid agencies. The Cures Act mandated that OIG submit a report to Congress—by March 31, 2020— that assesses the extent to which States had enrolled all providers that serve Medicaid beneficiaries. As part of the request, OIG must also provide Congress with information about the amount of Federal financial participation (FFP) that States received for services provided by Medicaid. How OIG Did This Review. We based this study on data from the 49 States and the District of Columbia (States) that responded to our survey. One State (Massachusetts) did not respond. We requested information on the extent to which States had enrolled all providers. We conducted follow-up with 39 States to clarify their survey responses. We asked States to report the Federal dollars associated with unenrolled providers. Many States could not report FFP associated with unenrolled MCO network providers. As a result, we used information about capitation payments (i.e., payments that States make to MCOs) from the Transformed Medicaid Statistical Information System (T-MSIS). Finally, we queried staff from CMS on their work to enforce the Federal provider enrollment requirements. What OIG Found. We found that—contrary to Federal requirements—23 States had not enrolled all providers serving Medicaid beneficiaries in their respective Medicaid programs, exposing them to potentially harmful providers that had not been screened for fraud, waste, and abuse. These 23 States reported that they had not enrolled all providers in Medicaid managed care or that they had not enrolled all ordering, referring, or prescribing (ORP) providers in Medicaid fee-for-service (FFS). 1. Twenty-one of the 23 States had not enrolled all providers in Medicaid managed care. The 21st Century Cures Act (Cures Act) required States to enroll these providers as of January 1, 2018. Most States had enrolled some, but not all, providers in the networks of managed care organizations (MCOs). However, four States had not attempted to enroll MCO network providers. The Centers for Medicare & Medicaid Services (CMS) also reported that it was not disallowing reimbursements to States for payments associated with unenrolled providers in MCOs’ networks because it does not have the authority to do so. 2. The Federal share of these 21 States’ expenditures for Medicaid managed care was $85 billion in 2018; States could not report the exact Federal share for individual unenrolled MCO network providers. 3. Ten of the 23 States had not enrolled all ORPs in Medicaid FFS as of January 1, 2017, the enrollment date required by the Cures Act. Of the 27 States that reported enrolling all providers, 11 States enrolled all providers according to Federal requirements and had enforcement controls. However, 16 of the 27 States reported that they were not collecting the required identifying and ownership information necessary for effectively screening Medicaid providers, or that they lacked enforcement controls to ensure ongoing State compliance with the Federal requirements.
- Copyright:
- The National Library of Medicine believes this item to be in the public domain. (More information)
- Extent:
- 1 online resource (1 PDF file (47 pages, 2 unnumbered pages))
- Illustrations:
- Illustrations
- NLM Unique ID:
- 9918282079706676 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/9918282079706676