The Medicare and Medicaid programs have most providers enrolled with inconsistent owner names across CMS, state Medicaid agencies, and names submitted to the HHS Office of Inspector General (OIG). The OIG believes that this inconsistency reflects noncompliance with requirements to report ownership changes, as well as raises concerns about the accuracy of information held by the agency. It recommended that CMS review providers with nonmatching names and take action to resolve the inconsistencies (OIG Report, OEI-04-11-00590, May 24, 2016; OIG Report, OEI-04-11-00591, May 24, 2016).
Ownership disclosures. The OIG believes that the Medicare and Medicaid programs can avoid attempting to recoup payments made to fraudulent and abusive providers by identifying risky providers at the outset. However, this requires obtaining accurate information, such as learning which entities may be associated with excluded individuals. Some fraud perpetrators attempt to conceal their entity’s true ownership from the program. In an attempt to strengthen program integrity activities, section 6401 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) imposed new oversight requirements on federal health care programs.
Providers enrolling in either Medicare or Medicaid must provide various types of information to CMS or the relevant state’s agency, including the name and address of any individual or corporation that has a controlling or ownership interest of at least 5 percent, or anyone who is a managing employee. CMS contracts with organizations to collect this information and upload it to the Provider Enrollment, Chain, and Ownership System (PECOS). CMS provides Medicaid agencies with limited access to PECOS to determine a provider’s Medicaid enrollment status, and encourages states to only process disclosure information after it is verified. States are required to confirm that disclosed owners are not excluded individuals.
Review and findings. The OIG collected information from each state Medicaid agency to learn how they verify completeness and accuracy of ownership information and whether they compared information with a list of excluded providers. Similarly, the OIG collected information from Medicare administrative contractors regarding how they process information. It also compared three sets of owner names for selected providers: names on record with the state agency, those on record with CMS for Medicare enrollment, and names submitted directly to the OIG by the providers themselves for evaluation.
Only 7 of 50 state Medicaid programs request all ownership information, and 14 did not verify the submissions for completeness or accuracy. Several did not check all exclusions databases before enrolling providers, nor did two CMS contractors. Only 4 out of 58 providers reviewed had matching owner names across all three compared sources.
Recommendations and response. The OIG recommended that CMS review the list of provider names that did not match and take appropriate action, educate providers on reporting requirements, coordinate more effectively with state Medicaid programs on the verification process, and ensure that CMS contractors consistently check exclusions databases. CMS concurred with all of the recommendations in the draft report.
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