About 12% of providers terminated from one state Medicaid program continued participating in other states’ Medicaid programs, according to a report from the Office of Inspector General.
Before the Affordable Care Act and Patient Protection was passed, providers could participate in another state’s Medicaid program, leaving the second State’s program vulnerable to fraud by the provider. However, the ACA now requires that each state terminates a provider’s participation in the Medicaid program if that provider was terminated from another program for reasons of fraud.
In 2014, the OIG published a report recommending improvements in the Centers for Medicare & Medicaid Services process of sharing termination information. Because the termination data from the CMS was not complete, the OIG went to each state Medicaid agency and asked for rosters of all Medicaid providers terminated in 2011 for cause.
Regardless of the ACA’s requirements, OIG found that 295 out of 2,539 providers terminated for cause in 2011 continued participating in another state’s Medicaid program through January 2012. More than 170 were still participating as of January 2014.
The OIG recommends that CMS works with state Medicaid agencies to develop uniform terminology to denote cause for terminations. CMS agreed to do this, and they will require Medicaid programs enroll providers participating in Medicaid Managed care.