The HHS Office of Inspector General (OIG) and the Government Accountability Office (GAO) have recently examined a number of Medicare and Medicaid provider screening and related program integrity issues. The OIG reports include the following:
- Enhanced Enrollment Screening of Medicare Providers: Early Implementation Results: The OIG examined the effectiveness of new CMS screening tools (e.g., placing providers in risk categories, increasing site visits, requiring fingerprinting, implementing an Automated Provider Screening system, and denying enrollment to providers whose owners have unresolved overpayments). While the OIG is unable to conclusively determine the extent to which these tools prevented fraudulent Medicare enrollment by illegitimate providers, the OIG did find that enrollment revalidation efforts led to a large number of revocations and deactivations of existing providers’ billing privileges. The OIG report includes recommendations for CMS to further strengthen its implementation of the enhanced screening procedures, including improvements to the site visit process.
- Medicare: Vulnerabilities Related to Provider Enrollment and Ownership Disclosure: The majority of Medicare providers reviewed had owner names on record with CMS that did not match (1) those submitted to the OIG and (2) those on record with state Medicaid programs. The OIG made several recommendations to address nonmatched owner names.
- Medicaid: Vulnerabilities Related to Provider Enrollment and Ownership Disclosure: The OIG found numerous vulnerabilities that could allow potentially fraudulent providers to enroll in state Medicaid programs and that limit states’ ability to provide adequate oversight. The OIG recommended that CMS work with state Medicaid programs to identify and correct gaps in their collection of all required provider ownership information and to verify such information.
- Medicaid Enhanced Provider Enrollment Screenings Have Not Been Fully Implemented: The OIG determined that state implementation of risk-based screening is incomplete, with most states reporting that they have not implemented fingerprint-based criminal background checks and 11 states reporting that they have not implemented site visits. The OIG offered a variety of suggestions for CMS to assist states with strengthening their Medicaid screening processes.
In addition, recent GAO reports include the following:
- Medicaid Program Integrity: Improved Guidance Needed to Better Support Efforts to Screen Managed Care Providers: GAO found that states and plans used information that was fragmented across 22 databases managed by 15 different federal agencies to screen providers for eligibility to participate in the Medicaid program. GAO recommended that CMS review and improve the databases used in screening and provide guidance to states on best practices for provider screening data among states and plans.
- Medicaid and CHIP: Increased Funding in U.S. Territories Merits Improved Program Integrity Efforts: GAO recommended that CMS examine and select from activities such as establishing program oversight mechanisms, assisting in improving program information, and conducting program assessments to develop a cost-effective approach to protecting territories’ Medicaid programs from fraud, waste, and abuse.
- Medicare: Claim Review Programs Could Be Improved with Additional Prepayment Reviews and Better Data: According to GAO, CMS does not have the information it needs to evaluate the Medicare Administrative Contractors’ performance and cost effectiveness in preventing improper payments, and CMS cannot compare performance across contractors. GAO recommended that CMS (1) request legislation to allow the recovery auditors to conduct prepayment claim reviews, and (2) provide written guidance on calculating savings from prepayment reviews.
- Medicare Advantage: Fundamental Improvements Needed in CMS’s Effort to Recover Substantial Amounts of Improper Payments: CMS currently uses risk adjustment data validation (RADV) audits to recover improper payments in the MA program. GAO recommended that CMS improve its processes for selecting contracts to include in RADV audits, enhance the timeliness of the audits, and incorporate recovery audit contractors into the RADV audits.