Playing fast and loose with Medicaid termination

Elizabeth Newman
Elizabeth Newman

There are many benefits to communicating to your cohorts in neighboring states, and not the least of it may be knowing when a provider is kicked out of Medicaid.

If there's something we can all agree about regarding the Affordable Care Act, it's a provision that says states must suspend the billing privileges of most providers who have been “terminated” or “revoked” by another state or Medicare. But a report in Reuters last week explored how providers terminated from Medicare or Medicaid are jumping states to find new life.

Each state has its own Medicaid guidelines and does not necessarily share information. The news organization laid out how a hospice physician and psychiatrist are among those who played the system by over billing, were found out, and moved along to the next state.

Another example mentioned in the report is Dynasplint Systems Inc. A few years ago, the Department of Justice joined a whistleblower case involving whether the company improperly billed Medicare for durable medical equipment for residents in skilled nursing facilities. The CEO says the company did not commit fraud. Whether or not that is true, five states suspended payments to Dynasplint in 2013. However, the company is still approved to bill in 24 states and has received $123,000 from state Medicaid programs since August 2013, Reuters found.

In another case, a spokeswoman for South Carolina's Department of Health and Human Services told Reuters directly that her state agency would not have known about a specific Georgia optometrist who pleaded guilty to Medicare fraud if she hadn't been contacted for comment. (Two thumbs up for investigative journalism!)

I'm sympathetic to both facilities and Medicaid programs trying to play whack-a-mole with terminating bad actors, given the lack of technological infrastructure. Still, I'm confident it would be a good use of taxpayer money to invest in a data-sharing system that would ultimately save the government a lot of money by reducing payments to terminated providers.

After all, we live in an era where we are constantly warned about nothing dying online. Teenagers are warned any “sexts” or illicit videos will reappear when they apply to college (or for a job), and it would be rare to go on a date these days without some light Googling. (Talk to me sometime about my suspicions of people who don't have a LinkedIn presence ... what are they hiding?)

Or, as a choice comment from a McKnight's reader on our story last week said, “Are you kidding? Inadequate state and federal data? Between the two, they can tell you how many BMs a resident in Kalamazoo had, but they can't match a provider's name/number to a list?” 

It's a fair point, and one that demands an answer from both federal and state governments. 

Elizabeth Newman is Senior Editor at McKnight's. Follow her @TigerELN.


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McKnight's Daily Editors' Notes features commentary on the latest in long-term care news and issues. Entries are written by Editorial Director John O'Connor, Editor James M. Berklan, Senior Editor Elizabeth Newman and Staff Writer Emily Mongan.

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