Kusserow’s Corner: OIG Faults the CMS System for Sharing Information about Terminated Providers

The ACA requires the CMS to establish a federal data-sharing system designed to prevent health care providers banned from one state’s Medicaid program from billing another state’s program, but the system isn’t working as intended. This is important for providers in that CMS has called for sanction screening for providers who have been terminated. In response to the mandates of the ACA, CMS established a web-based portal, the Medicaid and Children’s Health Insurance Program State Information Sharing System (MCSIS) for sharing terminated provider data among states in order to prevent terminated providers in one state from enrolling in another. Under this system, CMS and state agencies are to submit information about providers that meet CMS’s criteria for having been terminated “for cause” from Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP). State Medicaid agencies are then able to use the data to identify these providers and subsequently terminate them from their Medicaid programs, as is required under another section of the ACA.

The HHS Office of Inspector General (OIG) completed a review of the program and found that, two years after its creation, the data-sharing system contained no records from 17 states or the District of Columbia of doctors, nurses, or other health care providers who had been “terminated,” or banned from billing Medicaid, for fraud or other offenses. The OIG examined all provider records contained in MCSIS as of June 1, 2013, and (1) determined the extent to which MCSIS contained records submitted by CMS and State Medicaid agencies; (2) identified records that did not meet CMS criteria for reporting providers terminated “for cause” from Medicare, Medicaid, or CHIP; and (3) assessed whether records had complete identifying information about providers, including National Provider Identifiers (NPIs), provider types, and provider addresses. Among the faults cited by the OIG as of June 1, 2013 were the following:

  1. MCSIS contained records on terminated providers submitted by CMS for 33 state Medicaid agencies, but not for the remaining State Medicaid agencies.
  2. Contrary to CMS guidance, about one-third of the 6,439 records in MCSIS did not relate to providers terminated “for cause.”
  3. Over half of MCSIS records did not contain the National Provider Numbers (NPIs), a critical data element for accurately identifying providers.
  4. One-third of MCSIS records did not identify the provider types
  5. One-third of providers in the database had not been terminated, but had died, retired, left the state or stopped working with Medicaid of their own accord.
  6. One-fourth of the records lacked a provider address, and one-third lacked a provider specialty.

The OIG did not provide any estimates of the number of providers banned in at least one state but still billing in another. It identified a number of states that did not provided a report of a banned provider, including Colorado, Hawaii, Kentucky, Minnesota, Montana, New Hampshire, New Mexico, North Carolina, North Dakota, Oklahoma, Oregon, South Carolina, South Dakota, Texas, Utah, West Virginia, Wyoming, and the District of Columbia.

In addition, the OIG found a small number of banned provider reports from most states. They noted that California, Pennsylvania, Illinois, and New York accounted for 72 percent of all records submitted, whereas Louisiana submitted only one terminated provider, Massachusetts two, and Virginia nine.

The OIG called for improvements in CMS’s process for sharing information on terminated providers, and to make the process more useful to state Medicaid agencies in identifying providers that must be terminated “for cause” under federal law by Medicare, Medicaid, or CHIP. They recommended that CMS (1) require each state Medicaid agency to report all terminated providers, (2) ensure that the shared information contains only records that meet CMS’s criteria for inclusion, and (3) take action to improve the completeness of records shared through the process. CMS concurred with all recommendations.

The OIG noted in its report that in November 2013, subsequent to the timeframe of their study, CMS revised its process for sharing information about terminated providers; however the OIG held that the findings and recommendations in the report remained relevant to the new process. CMS administrator Marilyn Tavenner stated in response to the OIG report that CMS would explore options to implement mandatory state reporting, but provided no timeline for this.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2014 Strategic Management Services, LLC. Published with permission.