Medicaid Program Integrity:

Improved Guidance Needed to Better Support Efforts to Screen Managed Care Providers

GAO-16-402: Published: Apr 22, 2016. Publicly Released: May 6, 2016.

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Carolyn L. Yocom
(202) 512-7114
yocomc@gao.gov

 

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What GAO Found

GAO found that the selected states and Medicaid managed care plans face significant challenges in screening providers for eligibility to participate in the Medicaid program. Based on information we received from two selected states and 16 selected plans, GAO found that the states and plans used information that was fragmented across 22 databases managed by 15 different federal agencies to screen providers. These databases included databases that the Centers for Medicare & Medicaid Services (CMS) had not identified for use in screening providers. Officials from some states noted that these additional databases provided better assurance they would not enroll ineligible providers—i.e., providers who have been barred from participating in federal health care programs. Federal internal control standards stress the importance of collecting quality information to achieve objectives and assess risks. However, the variety of databases used for screening purposes beyond those identified by CMS, along with the current rate of improper payments to Medicaid providers, suggests that CMS might not have identified all reliable sources of information about ineligible providers that could help states and plans achieve program objectives. State officials and plan representatives also said that accessing and using fragmented information from multiple and disparate federal databases challenged their screening efforts. For example, they reported difficulties accessing certain databases, such as the Social Security Administration's Death Master File, and conducting and confirming identified provider matches across databases, particularly those not based on a unique national provider identifier. CMS has not coordinated with other agencies to address these challenges. Federal internal control standards state that agencies should use quality data that are complete, current, accurate, and accessible—and have a logical connection to the program—to achieve agency goals to reduce fraud. However, the difficulties states and plans experienced accessing databases and confirming matches could result in provider screening efforts that do not ensure that ineligible providers are accurately and consistently identified.

GAO also found that the selected states reviewed used inconsistent practices to make data on ineligible providers publicly available. States must ensure that none of their providers has been determined to be ineligible anywhere in the United States. Although CMS has issued guidance encouraging states to share data on ineligible providers through its Medicaid provider termination notification system, doing so is optional, not all states are using the list, and it is not available to Medicaid managed care plans. Moreover, CMS has not provided states with guidance on other ways to share their data on ineligible providers or how to access other states' data on ineligible providers. The 10 states GAO selected varied in how they shared data on ineligible providers. Plans are not required to make their own data on ineligible providers publicly available, and the 16 selected plans shared their data with states at differing intervals and, in rare cases, with other plans. The inconsistency with which this information is shared across states and plans creates the potential that providers could be ineligible in some states while still receiving payments from Medicaid in other states.

Why GAO Did This Study

GAO has reported that Medicaid remains a high-risk program, partly due to concerns about improper payments. Screening of providers is important to help prevent improper payments. Under managed care, states contract with plans to provide services to beneficiaries.

GAO was asked to examine the screening of managed care providers. GAO examined (1) states' and plans' experiences using federal databases to screen providers; and (2) how states and plans share data about ineligible providers. GAO interviewed officials from 10 states, selected generally based on enrollment and geography, and representatives from 16 plans from among these states. GAO reviewed those states' Medicaid program websites and plan contracts, and relevant federal laws, regulations, and guidance; and interviewed officials from CMS and the Department of Health and Human Services' Office of Inspector General.

What GAO Recommends

GAO recommends that CMS (1) consider additional databases used in screening, (2) collaborate with the Social Security Administration to improve access to the Death Master File, (3) coordinate with other agencies to develop a common identifier across databases, and (4) provide state Medicaid programs with guidance that establishes expectations and best practices on sharing provider screening data among states and plans. HHS concurred with our recommendations.

For more information, contact Carolyn L. Yocom at (202) 512-7114 or yocomc@gao.gov.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Priority recommendation

    Comments: HHS concurred with this recommendation. In August, 2018, CMS provided GAO with its analysis of 22 databases that were reported to GAO as being used by Medicaid managed care plans to screen providers. It determined that several were already in use by states and managed care plans and mentioned in CMS guidance. In its analysis, CMS concluded that 6 of the databases should be used for provider screening and 3 more contained information that was available from other databases. CMS concluded that 12 of the databases should not be implemented into the screening process and is still considering one of the databases for inclusion in the screening process.

    Recommendation: To improve the effectiveness of states' and plans' Medicaid managed care (MMC) plan provider screening efforts, the Acting Administrator of CMS should consider which additional databases that states and MMC plans use to screen providers could be helpful in improving the effectiveness of these efforts and determine whether any of these databases should be added to the list of databases identified by CMS for screening purposes.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

  2. Status: Closed - Implemented

    Priority recommendation

    Comments: HHS concurred with this recommendation. CMS has signed an Interagency Agreement that provides for the states' ability to access the SSA Death Master File and has made the Death Master File available to state officials. CMS has also engaged in regular communication with the states to provide assistance in accessing the Death Master File. CMS stated that, as of January 2018, 42 states had accessed the Death Master File as part of their screening and enrollment processes.

    Recommendation: To improve the effectiveness of states' and plans' MMC plan provider screening efforts, the Acting Administrator of CMS should collaborate with SSA to facilitate sharing CMS's Death Master File subscription with state Medicaid programs.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

  3. Status: Open

    Comments: HHS concurred with the recommendation. In the final Medicaid Managed Care Rule 2390-F. CMS added a requirement that states and managed care plans add the National Plan and Provider Enumeration System (NPPES) to the list of databases required to be checked when enrolling providers. Individuals or organizations are identified in NPPES through the use of a National Provider Identifier (NPI). However, this NPI applies only to NPPES and is not used in other databases that states and managed care plans check when enrolling providers. Therefore, the recommendation remains open.

    Recommendation: To improve the effectiveness of states' and plans' MMC plan provider screening efforts, the Acting Administrator of CMS should coordinate with other federal agencies, as necessary, to explore the use of an identifier that is relevant for the screening of MMC plan providers and common across databases used to screen MMC plan providers.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

  4. Status: Closed - Implemented

    Comments: HHS concurred with the recommendation. On January 4, 2017 CMS updated its Medicaid Provider Enrollment Compendium (MPEC), CMS's manual with guidance and clarifications regarding how state Medicaid agencies are expected to comply with federal regulations for screening providers. The updated MPEC provides detailed guidance and expectations about state reporting of Medicaid terminations to CMS's exclusions database, TIBCO. Specifically, it provides a template for states to use for reporting provider terminations and details the reporting process, including submission requirements, time frames, and minimum required data elements to match a provider in TIBCO.

    Recommendation: To improve the effectiveness of states' and plans' MMC plan provider screening efforts, the Acting Administrator of CMS should provide state Medicaid programs with guidance that establishes expectations and best practices on sharing provider screening data among states and MMC plans.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

 

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