OIG: Beef up terminated provider data

Shared information on sanctioned providers crucial for program integrity

The Centers for Medicare & Medicaid Services should improve its system for sharing data on providers whose participation in federal healthcare programs has been terminated, the Office of Inspector General announced Wednesday.

To house and share data on terminated providers, CMS uses a web-based portal called the Medicaid and Children's Health Insurance Program State Information Sharing System (MCSIS). States feed data into MCSIS on practitioners whose participation was revoked "for cause," meaning their billing rights ended for fraud, integrity or quality reasons as opposed to voluntary disenrollment.

But audited MCSIS data were often incomplete and erroneous, the OIG report found. The system contained records from only 33 states as of June.

And since about one-third of almost 6,500 records the OIG reviewed weren't for providers terminated for cause, many MCSIS records failed to meet CMS criteria for system entries. For example, the system held records for deceased providers.

Moreover, the OIG report found empty data fields: Thirty-three percent of audited records didn't specify provider type, and one-quarter had no provider addresses. More than half the records reviewed didn't contain a national provider odentifier (NPI), and some NPIs listed appeared to be wrong.

OIG recommended three fixes, all of which CMS accepted: Require each state Medicaid agency to report all provider participation terminations, ensure system records pertain only to for-cause terminations and improve completeness of records shared.

The Affordable Care Act requires CMS to share data with state agencies on terminated providers. Doing this can protect Medicare, Medicaid and the Children's Health Insurance Program from financial loss by preventing terminated providers from resuming government business.

A recent and costly example of this made headlines after a sweeping fraud bust in Washington, D.C., where one arrestee was an excluded provider who's now accused of bilking Medicaid out of $78 million.

For more:
- read OIG's announcement and report (.pdf)

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