Medicaid Fraud and Abuse: Stronger Action Needed to Remove Excluded Providers From Federal Health Programs
HEHS-97-63
Published: Mar 31, 1997. Publicly Released: Apr 30, 1997.
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Highlights
Pursuant to a congressional request, GAO reviewed the Department of Health and Human Services (HHS) Inspector General's (OIG) process for excluding providers from federal health care programs.
Recommendations
Recommendations for Executive Action
| Agency Affected Sort descending | Recommendation | Status |
|---|---|---|
| Other | The HHS Inspector General should establish consistent standards, performance goals or benchmarks, for the timely processing of state referrals. |
Closed – Not Implemented
OIG guidance requires that regional OIG officials decide within 60 days whether each exclusion referral will be processed for exclusion. This is the only benchmark the OIG contemplates for the exclusion process because there is so much variation in the time needed for exclusion processing. However, the OIG has increased its emphasis on promptly and responsively processing state referrals for nationwide exclusion. In fact, the number of exclusions processed based on state referrals nearly doubled from fiscal year 1997 to 1998. GAO was told that this was the result of GAO's work on this report, which caused the OIG to focus more on the part of the exclusion process that dealt with state referrals.
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| Other | The HHS Inspector General should, in collaboration with the Health Care Financing Administration, transmit OIG exclusion data either electronically or by diskette, including social security numbers, to state Medicaid agency officials responsible for enrolling and removing providers. |
Closed – Implemented
The OIG asked HCFA to comply with this GAO recommendation even before the report was issued, and HCFA began sending this information to appropriate state agencies shortly after the report was issued. In fact, the OIG has gone even further than GAO recommended by asking HCFA to provide similar information to managed care plans that have contracted to provide Medicare or Medicaid services.
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| Other | The HHS Inspector General should improve oversight of key state agencies that refers cases to the OIG, such as the state Medicaid agency and Medicaid fraud control unit, to ensure that states understand and comply with the statutory reporting requirements for state-removed providers. |
Closed – Implemented
The OIG has examined Medicaid agency state plans for requirements related to statutory reporting requirements for excluded providers; state plan provisions were considered inadequate. The OIG sent correspondence to HCFA to encourage HCFA to incorporate appropriate requirements in state plans. HCFA, however, has declined to amend state plans and does not plan to do so. Other agency actions were related to this recommendation, including implementing a tracking system to ensure accountability over exclusion cases, and expedited staff training and oversight over Medicaid fraud control units. Also, the report was credited with convincing states to do a better job of reporting providers barred from state Medicaid programs and providing the documentation the OIG needs to process exclusions.
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| Other | The HHS Inspector General should clarify to states that settlements and provider withdrawals to avoid formal sanctions should be reported to the OIG, in accordance with its regulations (42 C.F.R. 1001.601). |
Closed – Implemented
This recommendation should be addressed by state plan changes that the OIG plans to propose to HCFA. The OIG has examined Medicaid agency state plans for requirements related to statutory reporting requirements for excluded providers; state plan provisions were considered inadequate. The OIG sent correspondence to HCFA to encourage HCFA to incorporate appropriate requirements in state plans. HCFA, however, has declined to amend state plans and does not plan to do so. other agency actions were related to this recommendation.
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| Other | The HHS Inspector General should provide ongoing, clear and consistent guidance to the states on the documentation needed for timely processing. |
Closed – Implemented
Documentation needed for prompt processing of exclusion referrals is an issue to be addressed by draft correspondence from the OIG to HCFA regarding needed state plan changes. The OIG has examined Medicaid agency state plans for requirements related to statutory reporting requirements for excluded providers; state plan provisions were considered inadequate. The OIG sent correspondence to HCFA to encourage HCFA to incorporate appropriate requirements in state plans. HCFA, however, has declined to amend state plans and does not plan to do so. Other agency actions were related to this recommendation.
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