Health Reform WK-EDGE Medicaid programs dragging their feet on enhanced provider screening
Friday, June 3, 2016

Medicaid programs dragging their feet on enhanced provider screening

Medicaid programs dragging their feet on enhanced provider screening

By Kayla R. Bryant, J.D.

State Medicaid programs have not fully implemented required enhanced provider screening procedures under the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148). The HHS Office of Inspector General (OIG) found that most states did not begin to implement fingerprint-based criminal background checks, and report difficulties or concerns substituting alternative screening results from Medicare or other state Medicaid programs. The OIG recommended that CMS begin assisting states overcome these challenges in order to better ensure program integrity (OIG Report, OEI-05-13-00520, May 24, 2016).

Screening requirements. Section 6401 of the ACA required CMS to establish uniform provider screening requirements across state Medicaid programs, according to the risk for fraud, abuse, and waste that particular provider poses. States must use this risk-based screening upon enrollment, re-enrollment, and revalidation. CMS did not initially require fingerprint-based criminal background checks (FCBCs), but later issued guidance setting an implementation date of June 1, 2016. Upon realizing serious barriers to implementation, the agency gave states the option of submitting a FCBC plan to be approved by CMS by June 1, 2016.

State progress. Eleven of 47 states that the OIG surveyed stated that they did not conduct site visits for high- and moderate-risk providers as required, with six states reporting a lack of resources. This resulted in the enrollment of about 21,000 risky providers between March 2011 and August 2014 without site inspection. Although CMS allows states to substitute screening from the Medicare program or other state Medicaid programs, many states do not or only substitute a few results despite the benefits of reducing resources required to adequately screen providers. States have experienced difficulties obtaining CMS’ Medicare provider screening results, and both the OIG and the Government Accountability Office (GAO) are concerned that the Medicare screening process is not as thorough as it should be. States also have difficulty obtaining information from other Medicaid programs, and are reluctant to do so due to the variations in screening processes. Out of the states studied, 14 will not finish revalidating high- and moderate-risk providers by September 2016, the deadline CMS set for completion.

Recommendations. The OIG believes that the failure to implement enhanced screening procedures places state Medicaid programs at risk. Following the review, it recommended that CMS take the following actions: (1) assist states in implementing background checks for high-risk providers; (2) assist states in conducting site visits; (3) ensure the accessibility and quality of Medicare screening data; (4) develop a system for submitting and accessing screening results across the states; (5) strengthen minimum Standards for FCBCs and site visits; and (6) help states complete revalidation screening.

CMS concurred with all of the recommendations in the draft report, and outlined the efforts it has made to assist states in improving their processes. The OIG expressed concerns that the agency is taking too long to address the identified issues.

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