OIG: Most states not screening Medicaid providers properly

A majority of states have failed to implement risk-based screenings for Medicaid providers, according to a recent report by the Office of Inspector General.

Thirty-seven of the 47 states included in the report stated that they had not implemented fingerprint-based criminal background checks required for new and existing providers to be enrolled in the federal healthcare program.

Medicaid funding pays for roughly 65% of all nursing home care in the U.S., though the report did not break out findings specifically for skilled nursing in its conclusions.

Between March 2011 and August 2014, a total of 27,000 high-risk providers were allowed to enroll without completing the background checks, OIG researchers found.  Almost two-thirds of the providers had been newly enrolled without any knowledge of the state Medicaid programs.

The majority of the states that had not began conducting the screenings claimed they needed guidance on challenges they encountered during implementation process. However, the report says the states did not provide any explanation of the issues they faced.

Several states also failed to meet other requirements to enroll in Medicaid, which are regulated by the Center's for Medicare and Medicaid Services.

Eleven states admitted to allowing around 21,000 high- to moderate-risk providers join the program without conducting regular site visits to their facilities. Fourteen states also reported that they would not meet the September 2016 deadline for all providers to be revalidated.

OIG gave several recommendations to help complete screenings. The recommendations included assisting states to streamline the process, mandating site visits and creating a database for states to submit and reference screening results. 

Meanwhile, another new report by the OIG uncovered that the majority of state Medicaid providers are not reporting the proper ownership information.

Details on provider ownership were not verified for completeness or accuracy by 14 state 
programs. An equal number failed to confirm if providers were listed in the Medicaid exclusion database before allowing them to enroll.

Nearly every provider included in the report was also found to have submitted to the state owner names that were inconsistent with records sent to CMS. OIG said the mismatched names raise additional concerns about the validity of the information.

In order to enroll in Medicaid, providers must disclose names and addresses if an individual holds 5% percent or more of controlling interest, is a managing employee, or owns a business. In addition, criminal offenses must be reported by the providers before enrolling or renewing Medicaid.

To address the issues, CMS was recommended to require State Medicaid programs to check the exclusion database and review all providers who submit inconsistent ownership information.