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SCCE/HCCA

Terminated by Medicaid in One State? No Problem (just apply in another state)

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MontanaM RosenBy Michael Rosen
mrosen@providertrust.com

Prior to the passage of the Affordable Care Act, if a provider was terminated from Medicaid enrollment/eligibility in one state it could easily slip through the cracks and enroll in another state. Most states did not share or have access to a centralized database of terminated Medicaid providers. Obviously, this is not good for ferreting out fraud and preventing a terminated provider from hopping state lines and enrolling in another state.

Section 6501 and others were designed to curb this chink in the armor and to prevent, by centralizing, a terminated Medicaid provider from enrolling in another state. In fact, CMS was challenged under the Act to create a better mousetrap (database) and processes at the state Medicaid Fraud Control Units to meet the mandates of the ACA.

That was 2011. Now it is 2015.

Not much has changed or even progressed in that period of time, according to a new OIG report. The OIG not only found gaps, but has also formulated recommendations that CMS agreed to implement and address.

Let’s look at what the OIG found:

The OIG recognized that CMS had taken some steps to address this pervasive problem, but it is still not redressed. In February 2011, CMS issued regulations that required states to implement categorical risk-based screening of newly enrolled Medicaid providers and to re-validate all current Medicaid providers under new requirements created under the Affordable Care Act.

The idea was simple, the tools provided, but the execution by states was poor.

[bctt tweet=”Terminated by Medicaid in One State? No Problem (just apply in another state) @mrosen64″]

The HHS OIG, Daniel Levinson, conducted an audit and found that:

  1. Continued participation from terminated providers in other state’s Medicaid programs was still occurring in 2014.
  1. 12% of the 2,539 providers terminated for cause in 2011 continued participating in another state’s Medicaid program as late as January 2014.
  1.  States were still confused on terminology and identifying all terminations for cause and differentiating these terminations from other administrative actions that a state reports.
  1.  Further complicating a state’s ability to terminate providers is the challenge created by those states that do not enroll providers in participating in its Medicaid managed care organizations (MCO).
  1. Finally, states were confused regarding whether an active licensure status from the state licensing board precluded terminating for cause.

OIG Recommended and CMS Agreed to the following in order to fix this problem:

  1.  CMS work with states to develop uniform terminology to clearly denote for cause terminations.
  1.  Require that state Medicaid programs enroll all providers participating in Medicaid managed care, and
  1.  CMS furnish guidance to state agencies that termination is not contingent upon the provider’s active licensure status at the state licensing board.

For a more detailed review of the Report click here.

Conclusion:

This is very troubling since a provider can be terminated for cause in one state Medicaid agency, but simply move to another state, which does not check or have good processes in place to prevent enrolling such terminated provider into their state. Effective compliance monitoring includes a combination of monthly nationwide (state and federal) exclusion monitoring. If your plan does not include such searches, you may be enrolling, hiring, contracting with and/or submitting bills for federal healthcare program dollars of an excluded and/or terminated provider.

Michael Rosen is co-found of Provider Trust and a frequent contributor to the Provider Trust blog.

 

Can the Doctor Refer, Order or Prescribe?

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M RosenBy Michael Rosen
mrosen@providertrust.com

Seems like a simple question. But the answer may surprise you. There are three things that are needed for a referral to be legitimate and to avoid potential civil fines and penalties.

1.  Does the Physician have a current license without restrictions?

2.  Is the Physician privileged or credentialed at the hospital?

3.  Is the Physician excluded from participating in Medicare/Medicaid or other federal healthcare dollar reimbursed programs?

Each of these must be met in order for the Physician to be able to refer a patient to a hospital or other related services for which federal healthcare dollars are involved.  The OIG has made it clear.

“If you are excluded by OIG from participation in the Federal healthcare programs, then Medicare, Medicaid, and other Federal health care programs, such as TRICARE and the Veterans Health Administration, will not pay for items or services that are furnished, ordered or prescribed. Excluded Physicians many not bill directly or indirectly for treating Medicare and Medicaid patients, nor may their services be billed indirectly through an employer or a group practice.  In addition, if the Physician furnishes services to a patient on a private-pay basis, no order or prescription that is given to that patient will be reimbursed by and Federal healthcare  program.”

Further the OIG states: “This responsibility requires screening all current and prospective employees and contractors against the OIG’s List of Excluded Individuals and Entities (LEIE).  In fact, the OIG has a set of training materials and even offers a 1 Hour Continuing Medical Education Credit on its site on this and other Physician related compliance issues.

Finally, the OIG has posted a very instructive Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs, dated May 8, 2013 that addresses the Physician referral issues. (p.p. 8-13).

On a related note and advice from the OIG, footnote 10 states that “Some excluded practitioners will have valid licenses or Drug Enforcement Agency (DEA) numbers. Therefore, it is important not to assume that because a prescription contains a valid license number or DEA number, the practitioner is not excluded.”

If the excluded Physician has a management, administrative or billing role in a third party company, then such items claimed for reimbursement will not be eligible for payment due to the excluded Physician’s role. “This prohibition applies even if the administrative and management services are not separately billable.”  (p.7)

[bctt tweet=”@mrosen64 An effective Exclusion Monitoring #Compliance Program will include searching for exclusions on Physicians & referring Physicians” via=”no”]

Summary:

An effective Exclusion Monitoring Compliance Program will include searching for exclusions on Physicians and referring Physicians.  Otherwise you may be exposing your organization to Civil Fines and Penalties.