GAO: 'Fragmented' data scuttles Medicaid managed care provider screenings

States and Medicaid plans screen providers with data in 22 databases from 15 different agencies, the GAO report said
States and Medicaid plans screen providers with data in 22 databases from 15 different agencies, the GAO report said

Fragmented databases are preventing states and Medicaid managed care plans from properly screening eligible providers, according to a new report from the U.S. Government Accountability Office. The result is inconsistencies that allow providers ineligible to receive payments in some states receiving it in others, the report says.

The GAO's data, published in April but publicly released on Friday, found that certain states and Medicaid plans used information for screening that is spread across 22 databases managed by 15 different federal agencies. Some of those databases have not been identified by the Centers for Medicare & Medicaid Services as appropriate for provider screenings, the GAO said.

Some of the 10 states included in the GAO's analysis told the agency that the additional databases have given them more assurance that they wouldn't enroll ineligible providers, including those who have been barred from participating in federal healthcare programs.

“The difficulties states and plans experienced accessing databases and confirming matches could result in provider screening efforts that do not ensure that ineligible providers are accurately and consistently identified,” GAO said.

Providers can become ineligible for the Medicaid program for convictions of Medicaid-related fraud, patient abuse and suspension or revocation of a medical license.

The agency added that the variety of databases suggests “CMS might not have identified all reliable sources of information” on ineligible providers. CMS has not worked with other federal agencies to address the screening challenges, the GAO noted.

The GAO recommends that CMS consider additional databases for use in provider screenings, coordinate with other agencies to create a common identifier across the databases, and give state Medicaid programs guidance on best practices for sharing provider screening data among states and plans.

The report also encourages CMS to work with the Social Security Administration to improve access to the administration's “Death Master File,” an index containing records of deceased persons, which states and plans have said they have trouble accessing.

The U.S. Department of Health and Human Services agreed with all of the recommendations, the GAO said.