Expanded Federal Authority Needed To Protect Medicare and Medicaid Patients From Health Practitioners Who Lose Their Licenses

HRD-84-53: Published: May 1, 1984. Publicly Released: May 1, 1984.

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GAO obtained information on health care practitioners in three states who had their licenses revoked or suspended to determine whether they were relocating and continuing to treat patients under Medicaid and Medicare programs in other states.

GAO found that, when a state licensing board revokes or suspends a practitioner's license, Medicare and Medicaid are informed that he can no longer legally provide services in that state. However, sanctioning action by one state does not automatically result in sanctioning by other states where the practitioner holds licenses. GAO obtained information on 328 sanctioned practitioners who had their licenses revoked or suspended for a year or more during the period from January 1977 to December 1982. The practitioners were sanctioned for such offenses as drug trafficking, malpractice, alcohol and drug abuse, immoral conduct, private insurance fraud, and submitting false Medicare or Medicaid claims. Of the 328 sanctioned practitioners, 122 held licenses in at least one state other than the state which took action against them; 39 relocated and enrolled in the Medicare and/or Medicaid programs; 10 relocated, but no Medicare or Medicaid participation was identified; and 43 held licenses in other states but could not be located. Under Medicare and Medicaid law, the Department of Health and Human Services (HHS) can exclude practitioners from participation in these programs only for acts committed against the program or its beneficiaries. GAO believes that HHS could better protect Medicaid and Medicare beneficiaries if it had extended authority to exclude unqualified practitioners from participating in these programs.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: HHS proposed legislation included all of the items that GAO recommended. The recommended GAO legislation was included in P.L. 100-93.

    Recommendation: The Secretary of Health and Human Services should revise the HHS practitioner exclusion legislative proposal so that it includes provisions authorizing HHS to sanction nationally Medicare and Medicaid practitioners who are: (1) excluded by any state Medicaid program; (2) excluded by Medicare; (3) convicted of crimes involving any federal or nonfederal health program; or (4) sanctioned by any state licensing board.

    Agency Affected: Department of Health and Human Services

  2. Status: Closed - Implemented

    Comments: Bills were reintroduced in the Senate and House which would require HHS to have the recommended information available. HHS was required to establish the recommended database by P.L. 100-93.

    Recommendation: The Secretary of Health and Human Services should direct the HHS Inspector General to include in the Health Care Program Violation Information System all practitioners sanctioned by state licensing boards.

    Agency Affected: Department of Health and Human Services


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