CMS’s Process for Sharing Terminated Provider Information and State Exclusion Monitoring
In March, the OIG published a report titled, “CMS’s Process for Sharing Information About Terminated Providers Needs Improvement.” As the title suggests, DHHS has determined that CMS does not properly share information regarding terminated providers with other states. As we’ve discussed before, section 6501 of the Patient Protection and Affordable Care Act (ACA) requires State Medicaid programs to terminate participation of providers if terminated under Medicare, another State Medicaid program, or CHIP. That’s why section 6401 of the ACA requires that CMS establish a process for sharing information about terminated providers with State agencies. But why should your organization be concerned about the OIG’s findings regarding CMS’s web-based portal, the Medicaid and Children’s Health Insurance Program State Information Sharing System (MCSIS)?
The OIG’s Findings: Incomplete Information
In this study, the OIG determined that the MCSIS contained records on terminated providers submitted by CMS and 33 State Medicaid agencies and did not contain records from the remaining State Medicaid agencies. The findings, however, suggest that CMS’s information-sharing process needs improvement to make it useful for State agencies to identify providers that the States must terminate from Medicaid in accordance with section 6501 of the ACA. Many of the records in the MCSIS had empty data fields, including ones that are critical for identifying providers, including the NPI, provider type, and address.
The Case for Checking the State Medicaid Exclusion Lists
The OIG report indicates that CMS’s system is flawed and contains incomplete information about terminated providers. Although this report does not address how state exclusions are incorporated in the OIG’s List of Excluded Individuals and Entities (LEIE), it does demonstrate the issue of sharing exclusion information across states. As mentioned earlier, section 6501 requires that providers terminated in one State be terminated in others. It is, therefore, imperative that healthcare organizations monitor the State Medicaid Exclusion Lists, as another State’s termination determines whether a provider can participate in federal healthcare programs in any State.
If your current exclusion screening program only relies on the OIG LEIE or GSA SAM as the only exclusion lists checked, you could be missing exclusion information in at least 34 State Medicaid Exclusion Lists that are publicly available as of May 1, 2014. From our research, it’s possible to find State exclusions as old as two years that are still not available in the OIG LEIE. While the State Medicaid Exclusion Lists do not contain individually as much information as the LEIE, it is nevertheless publicly available information that you are responsible for checking.
Until CMS improves its process for sharing exclusion information and the States report exclusion information in a timely manner to the OIG, it is highly recommended that healthcare organizations monitor the State Medicaid Exclusion Lists as part of their exclusion screening program. It’s in accordance with section 6501 of the ACA, and it can help you identify excluded individuals and entities that may otherwise go unnoticed.
References: CMS’s Process for Sharing Information About Terminated Providers Needs Improvement (Report). U.S. Department of Health and Human Services, Office of Inspector General. March 2014.