Why GAO Did This Study
“A crucial component of protecting the integrity of the Medicaid program is ensuring that only eligible providers participate in Medicaid. States’ non-compliance with provider screening and enrollment requirements contributed to over a third of the $36.3 billion estimated improper payments in Medicaid in 2018. To improve the integrity of the Medicaid program, PPACA and the 21st Century Cures Act established new requirements for screening and enrolling providers and expanded enrollment to include additional provider types.”
What GAO Found
“Officials from seven selected states that GAO interviewed described challenges they faced implementing new Medicaid provider screening and enrollment requirements, established by the Patient Protection and Affordable Care Act (PPACA) in 2010 and the 21st Century Cures Act in 2016. These challenges included establishing procedures for risk-based screenings, using federal databases and collecting required information, and screening an increased volume of providers. Due in part to these challenges, officials from five of the seven selected states told GAO they had not implemented certain requirements. For example, one state plans to launch its new information technology system, which automates screenings, before it will enroll providers under contract with managed care organizations, as required under these laws…”
What GAO Recommends
“GAO recommends that CMS (1) expand its review of states’ implementation of provider screening and enrollment requirements to include states that have not participated in optional consultations; and (2) for states not fully compliant with the requirements, annually monitor the progress of those states’ implementation. The Department of Health and Human Services, the department that houses CMS, concurred with both recommendations.”
Read the full 44-page report here.
Source: Medicaid Providers: CMS Oversight Should Ensure State Implementation of Screening and Enrollment Requirements – November 12, 2019. GAO.
