- The Washington Times - Wednesday, August 5, 2015

Health providers banned from state Medicaid programs for fraud or other serious reasons are still doing business in other states despite Obamacare’s prohibition on the practice, according to a government audit that said $7 million in payments would have been withheld if the states had a better way to communicate.

The Affordable Care Act of 2010 said states must terminate any provider that’s been banned from another state’s Medicaid program “for cause,” meaning fraud or issues with their integrity or quality.

Despite this provision, investigators said 12 percent of providers, or 295 out of 2,539, that were terminated in 2011 were still participating in Medicaid in 2012, and 172 of them made it to at least January 2014, the Health and Human Services Department’s inspector general said.

Medicaid program paid $7.4 million to 94 of these providers for services they performed after they were kicked out of the program in another state. States said they didn’t make any payments to the remaining 201 providers.

“Nonetheless, it remains concerning that these providers continued as participating providers who could treat Medicaid beneficiaries,” the IG report said.

The inspector general said the problem is that states cannot separate which providers were banned “for cause” versus those booted for administrative reasons, and there isn’t a comprehensive clearinghouse to identify all of the terminations around the country.

The Centers for Medicare and Medicaid Services (CMS) set up a termination database for this purpose, but states are only encouraged — not required — to participate, the inspector general said.

Some couldn’t terminate providers who operated through a managed care system but didn’t actually enroll in the state Medicaid program, or officials thought an active license from a state board insulated the providers from the Obamacare rule.

States also used a patchwork of terminology to describe why a provider was kicked out of their programs, resulting in confusion.

The inspector general said CMS should use uniform terminology, require all states to enroll managed care providers in their state Medicaid programs and clarify that termination is not tethered to a provider’s licensing status.

Agency officials said they agreed with the recommendations are will better educate the states and issue new guidance, although the inspector general encouraged them to do more.

“Although CMS described steps it had taken to improve the process of sharing information regarding terminated providers, it did not indicated that it planned to require state reporting of all terminations,” the report said. “Unless CMS requires such reporting, we believe that a centralized data source will not be comprehensive.”

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