HCFA and States Could Work Together to Better Ensure the Integrity of Providers

T-HEHS-00-159: Published: Jul 18, 2000. Publicly Released: Jul 18, 2000.

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William J. Scanlon
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Pursuant to a congressional request, GAO discussed the Health Care Financing Administration's (HCFA) efforts to better ensure the integrity of providers who bill the Medicaid program, focusing on: (1) why it is important to take steps to ensure that only honest providers bill federal health care programs; (2) what Medicare is doing to strengthen its provider enrollment process; (3) what states are doing to ensure provider integrity in the Medicaid program; and (4) what additional opportunities exist to improve these efforts.

GAO noted that: (1) with hundreds of millions of claims to process each year, Medicare and Medicaid must rely in part on provider honesty in billing; (2) as a result, it is critical to protect program funds by making efforts to ensure that only legitimate providers bill these programs; (3) recent incidents of Medicaid fraud perpetrated by dishonest medical equipment suppliers in California and other cases of Medicare and Medicaid fraud underscore these programs' vulnerability; (4) although HCFA has made revamping its provider enrollment process a priority for Medicare, it has not sought similar efforts in state Medicaid programs; (5) Medicaid state agencies report differing practices to ensure provider integrity, with only nine states reporting that they perform comprehensive provider enrollment activities; (6) because HCFA is redesigning its Medicare provider enrollment process, the HCFA Administrator has suggested that developing a joint Medicare/Medicaid provider enrollment process might be beneficial for both programs; and (7) thus, HCFA and the states have an additional opportunity to work together to develop new procedures for Medicaid that could better ensure provider integrity for both programs while minimizing the administrative burden and cost.

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