Medicaid Enrollment For Providers Got Tougher, But Many States Lack Enhanced Screening

The Affordable Care Act (ACA) heralded a new era of provider enrollment screenings not only in the Medicare program but also in States’ Medicaid programs. A series of new Office of Inspector General (OIG) reports reviewed the effectiveness of the States’ implementation of the new screening requirements in the Medicaid programs and found areas in need of improvement.

Enhanced Screened Not Fully Implemented

Similar to Medicare, the ACA requires States to screen Medicaid providers according to their risk for fraud, waste, and abuse using enhanced screening procedures for enrollment, revalidation or re-enrollment purposes.

OIG found that State implementation of risk-based screening is incomplete. OIG took issue with the fact that most States did not implement fingerprint-based criminal background checks while waiting for CMS guidance. This is so despite the fact that CMS did not require States to conduct these checks in the Final Rule and the December 2011 guidance, pending additional guidance, which, OIG noted critically, CMS issued after a lengthy delay of four years. (States, however, had discretion to implement fingerprint and criminal background checks in the absence of CMS guidance).

OIG also identified 11 States that have not implemented site visits and some States that still enrolled and revalidated thousands of providers categorized as posing a high or moderate risk to Medicaid even though such States have not fully deployed all screening activities for providers in such categories. Finally, 14 States reported that they would not finish revalidating the current high- and moderate-risk providers by the September 25, 2016 deadline.

Medicaid Programs Noncompliant with Ownership Disclosure Requirement

Federal regulations require that, among other things, providers enrolling in Medicaid must disclose to States specific information, including the name and address of any person (individual or corporation) that has an ownership or controlling interest of 5 percent or more. States’ Medicaid forms must collect this required information and although there is no requirement that States verify this information, CMS advises that States verify the completeness and accuracy of the data. Enrolling or revalidating providers must also report whether any owners have been convicted of a criminal offense. Likewise, enrolled Medicaid providers must report changes of ownership to State Medicaid programs within 35 days of the change.

OIG’s study revealed vulnerabilities in the way the States handle the requirement of disclosing ownership information. For example, the OIG found that few States requested disclosure sufficient to meet the full federal disclosure of ownership information requirement. OIG’s report found that 14 State Medicaid programs did not verify the completeness or accuracy of provider ownership information. Fourteen State Medicaid programs also reported to OIG that they did not check all required exclusions databases (the OIG’s exclusion list as well as the System for Award Management or SAM). Eleven of these State Medicaid programs reported that they check one exclusions database but not the other (7 checked the OIG’s list, 4 checked SAM). OIG’s report noted, however, that 17 State Medicaid programs reported checking both the OIG’s and SAM lists at least monthly.

OIG also found that the majority of owner names in its review failed to match names that providers submitted to OIG or those on record with CMS. For example, of the 62 names reviewed only 4 providers matched across all three Medicaid, CMS and OIG records. For ten providers, none of the owner information matched between Medicaid and OIG information and 53 providers evaluated contained only partial matches (86% nonmatch rate). For records compared between State Medicaid provider owner information and that of CMS, the error rate of nonmatch was 90 percent.

OIG also noted that of those Medicaid providers it reviewed, the overwhelming majority did not timely submit change of ownership information (required to be provided within 35 days of the change).

If yoy have questions about Medicare or Medicaid enrollment, revalidation, re-enrollment, revocation or have other health law questions, please contact our office.