Medicaid termination doesn't always cross state lines: OIG

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Twelve percent of providers terminated from a state Medicaid program continued participating in other states, a new government study has found.

There were 295 providers kicked out for cause in 2011 that were still participating as of January 2012, according to an August 6 report from the Office of the Inspector General. One hundred seventy- two providers still remained in January 2014.

State Medicaid programs paid approximately $7.4 million over three years to 94 providers after they had been terminated for cause by another state.

Terminating providers can be especially challenging when states are not enrolling providers in Medicaid managed care organizations, the OIG noted. Some states also think if a provider has an active license from a state licensing board, the state Medicaid agency should defer to the judgment of the board. But termination is not contingent on a provider's licensure status, according to the Affordable Care Act.

There is a lack of centralized data listing providers terminated for cause, the OIG said. Terms can vary — one state may use the word “exclusion” while another uses “licensure modification.” 

“To date there has been no single source that is comprehensive enough to allow states to identify all the fee-for-service and Medicaid managed care providers enrolled in State Medicaid programs whose terminations for cause warrant action pursuant to section 6501 of the ACA,” the OIG wrote.

CMS should continue to work with state Medicaid agencies to develop uniform terminology to denote cause for terminations, the OIG stated. CMS agreed and said it would require Medicaid programs to enroll providers participating in Medicaid managed care.


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