Medicaid managed care programs remains vulnerable to improper payments to providers, according to a recent Government Accountability Office report to a Senate Committee on Homeland Security and Governmental Affairs, since the information needed to screen providers for inclusion in the program is often fragmented and unavailable.
The GAO found that in two states and 16 selected plans, the states and plans used information that was fragmented across 22 databases managed by 15 different federal agencies.
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State officials and plan representatives told the GAO they had trouble accessing certain databases, such as the Social Security Administration's Death Master File. They also had difficulty confirming identified provider matches across databases, particularly those not based on a unique national provider identifier, the GAO said. Under the managed care delivery model, states contract with plans to provide Medicaid-covered services to beneficiaries, paying a set amount per beneficiary, per month in capitation payments.
The Centers for Medicare and Medicaid Services estimated that in 2015, $29 billion, or 9.78 percent of federal Medicaid expenditures went towards improper payments, the GAO told Senator Thomas R. Carper, D-Delaware, ranking member of the Committee on Homeland Security and Governmental Affairs.
In 2011, of 881,000 Medicaid providers in four states, hundreds of providers were potentially receiving improper Medicaid payments due to having suspended or revoked medical licenses, invalid addresses, being identified as deceased in federal death files, or having been been excluded from federal programs such as Medicaid, according to the report.
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The GAO was asked to examine the screening process of managed care providers in select states where the state contracts with plans to provide services to Medicaid beneficiaries. It examined how the states and plans use federal databases to screen providers, and how they share information about ineligible providers.
These databases include those CMS has not identified for use in screening providers, the GAO said in its report. Officials from some states noted these additional databases provided better assurance they would not enroll ineligible providers, such as those who have been barred from participating in federal healthcare programs.
However, the variety of databases used for screening purposes beyond those identified by CMS, along with the current rate of improper payments to Medicaid providers, suggests that CMS might not have identified all reliable sources of information about ineligible providers that could help states and plans, the GAO said.
CMS also has not coordinated with other agencies to address these challenges.
Although CMS has issued guidance encouraging states to share data on ineligible providers through its Medicaid provider termination notification system, doing so is optional, not all states are using the list, and it is not available to Medicaid managed care plans, the GAO said.
The 10 states GAO selected for screening varied in how they shared data on ineligible providers. Plans are not required to make their own data on ineligible providers publicly available, and the 16 selected plans shared their data with states at differing intervals and, in rare cases, with other plans.
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The inconsistency of shared information across state borders creates the potential that providers could be ineligible in some states while still receiving payments from Medicaid in other states, the GAO said.
The GAO recommends that CMS consider additional databases used in screening; collaborate with the Social Security Administration to improve access to the Death Master File; coordinate with other agencies to develop a common identifier across databases; and provide state Medicaid programs with guidance on sharing provider screening data among states and plans.
Health and Human Services concurred with its recommendations, the GAO report said.
Twitter: @SusanJMorse