Idaho paid six providers about $820,000 in Medicaid payments after those providers had been cut off from other states’ Medicaid programs for reasons including “fraud, integrity or quality,” according to a federal report.
Two additional providers were still in Idaho Medicaid’s roster but did not receive payments.
Idaho wasn’t alone. Its payments made up a fraction of the millions of dollars paid out nationally to disqualified providers.
The U.S. Department of Health and Human Services Office of Inspector General found that 295 of 2,539 providers, or 12 percent, who were terminated “for cause” from a state’s Medicaid program in 2011 were still participating in another state’s Medicaid program as of January 2014.
“These Medicaid programs paid $7.4 million to 94 providers” for services they performed after having been cut off by a different state, the report said.
Before the Affordable Care Act became law in 2010, a state could terminate a provider from its Medicaid program, but the provider could keep participating in another state’s Medicaid program, “leaving the second state’s program vulnerable to fraud, waste or abuse,” the report said.
A provision in the Affordable Care Act, often called Obamacare, aimed to close that loophole. But it isn’t always working.
According to the Idaho Department of Health and Welfare, there is a gap in the information-sharing system among states that makes it hard to tell when potentially troublesome providers have been cut from other states’ Medicaid programs.
“Idaho Medicaid does not receive this information directly from other states,” department spokesman Tom Shanahan said.
The Office of the Inspector General analyzed data showing which providers were terminated in each state in 2011 and which ones were allowed to bill Medicaid as of Jan. 1, 2012.
“All but one of the (Idaho Medicaid) providers on the list of (other states’) terminated providers from the OIG were terminated in Oregon, and no termination reasons were provided,” Shanahan said. “A representative of the Oregon Medicaid program advised Idaho Medicaid against terminating providers based on the list from OIG” because of terminology and other issues that make the data unreliable.
The OIG ended up obtaining provider information directly from the states — including Idaho — because the data it collected through the federal process for sharing information among states “was not comprehensive and complete,” the report said.
“The challenges that states face ... include not having a comprehensive data source for identifying all terminations for cause, and difficulty differentiating such terminations from other administrative actions that a state reports,” the OIG found.
It also said more than half of states that contract out administration of their Medicaid programs did not require all providers to be directly enrolled with the state Medicaid agency — further complicating the process of preventing bad providers from working for other states’ Medicaid programs.
The OIG recommended that the Centers for Medicare and Medicaid Services work with states to fix the communication problems.