Fraud and Abuse:

Providers Excluded From Medicaid Continue to Participate in Federal Health Programs

T-HEHS-96-205: Published: Sep 5, 1996. Publicly Released: Sep 5, 1996.

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GAO discussed whether the Department of Health and Human Services' (HHS) Office of Inspector General's (OIG) process for removing fraudulent health care providers from all federal health programs. GAO noted that: (1) weaknesses within HHS OIG allow sanctioned health care providers to remain in federal health care programs; (2) these weaknesses include lengthy delays in the OIG decision-making process, inconsistencies among OIG field offices, states not informing OIG of the providers withdrawing from state Medicaid programs, and states using information from OIG to remove excluded providers from state programs; (3) these problems compromise the financial integrity of the Medicaid program; (4) OIG field offices are unable to account for the number of referrals they receive from OIG state offices; (5) health care providers deemed unfit in one state continue to participate in Medicaid programs in other states; (6) OIG needs to consider whether it is capable of protecting beneficiaries from substandard care and ensuring the integrity of the federal health care system; and (7) OIG could become more efficient in detecting fraudulent health care providers by providing more guidance for OIG field staff, timely preparing individual case files, clarifying guidance for OIG field offices, ensuring that states act quickly in removing OIG-excluded providers from Medicaid participation, and requiring states to report providers' voluntary withdrawal from Medicaid programs to OIG field offices.

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