States could do more to prevent terminated providers from serving 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 -- legislation & jurisprudence Medicaid -- legislation & jurisprudence United States United States. Department of Health and Human Services
- Genre(s):
- Technical Report
- Abstract:
- The Cures Act includes specific program integrity requirements to ensure that States do not spend Medicaid funds on items and services associated with terminated providers. In addition, as of July 1, 2018, the Cures Act requires State contracts with MCOs to include a provision that providers who were terminated from Medicare, Medicaid, or CHIP cannot participate in their Medicaid managed care networks. The Cures Act required OIG to determine the following: (1) whether providers in CMS’s termination database are terminated from Medicaid in all States, (2) the amount of Medicaid payments associated with terminated providers, (3) whether State contracts with MCOs included a required provision that prohibits providers terminated from Medicare, Medicaid, or CHIP from participating in Medicaid managed care networks, and (4) the amount of Medicaid payments to MCOs that did not have the required provision in their contracts. How OIG Did This Review. From CMS, we requested its termination database, which contains information on terminated providers reported by States. We requested rosters of enrolled providers from States. We reviewed State enrollment rosters dated between January and May 2019. We compared terminated providers listed in CMS’s February 2019 termination database to the providers in States’ rosters of enrolled Medicaid providers. We also identified fee-for-service claims and managed care encounter records associated with terminated providers on or after July 1, 2018. We determined whether these providers were enrolled in Medicaid. Finally, we examined State contracts with MCOs to determine whether States included in their contracts with MCOs a provision that terminated providers are terminated from all Medicaid managed care networks. What OIG Found. Nearly 1,000 terminated providers—or 11 percent of all terminated providers— were inappropriately enrolled in State Medicaid programs or were associated with $50.3 million in Medicaid payments after being terminated. These providers had been terminated for reasons such as criminal convictions, licensure issues, and provider misconduct and thus potentially posed a risk to beneficiaries’ safety and quality of care. In addition, only eight States’ managed care contracts all clearly included the provision—required by the 21st Century Cures Act (Cures Act)—that prohibits terminated providers from participating in Medicaid managed care networks. This vulnerability may allow terminated providers to serve Medicaid beneficiaries and reduce States’ ability to limit these providers’ participation in Medicaid managed care networks. At the time of our review, the Centers for Medicare & Medicaid Services (CMS) did not check for this Cures Act-required provision when reviewing States’ contracts with managed care organizations (MCOs). Overall, States paid at least $62.3 billion in capitation payments to plans under contracts that did not include the required provision. Finally, States did not always provide complete and accurate Medicaid data to CMS, which limited the breadth of our analysis of claims, encounter records, and payments associated with terminated providers. Therefore, our findings understate the payments associated with contracts that did not contain the required Cures Act provision and may understate the payments associated with terminated providers.
- Copyright:
- The National Library of Medicine believes this item to be in the public domain. (More information)
- Extent:
- 1 online resource (1 PDF file (37 pages))
- Illustrations:
- Illustrations
- NLM Unique ID:
- 9918282079806676 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/9918282079806676