Fraud and Abuse: Providers Excluded from Medicaid Continue to Participate in Federal Health Programs : Statement of Leslie G. Aronovitz, Associate Director, Health Services Quality and Public Health Issues, Before the Subcommittee on Human Resources and Intergovernmental Relations, Committee on Government Reform and Oversight, House of Representatives

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The Office, 1996 - Fraud - 10 pages
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Page 2 - mandatory exclusions. " 2OIG exclusions are effective with respect to Medicare (title XVIII of the Social Security Act) and state health care programs, defined as Medicaid (title XIX), Maternal and Child Health Services Block grant (title V), and Block Grants to States for Social Services (title XX) . As a result of the Federal Acquisition Streamlining Act of 1994, which mandates and expands the governmentwide effect of all debarments, suspensions, and other exclusionary actions to federal procurement...
Page 5 - HHS regulations define the term "otherwise sanctioned" as intending to cover all actions that limit the ability of a person to participate in the program, regardless of what such an action is called, including situations in which an individual or entity voluntarily withdraws from a program to avoid a formal sanction (42 CFR 1001.601).
Page 3 - Medicaid fraud control units iMFCU),* and others. For mandatory cases, they assemble and forward to headquarters the case files containing evidence of a provider's criminal conviction. For referrals falling under the permissive exclusion authorities, the field offices receive documents related to disciplinary actions taken by state Medicaid agencies, licensing boards, or others. They assess the relevant facts and forward to OIG headquarters the cases they recommend for exclusion. OIG headquarters...
Page 5 - This effectively excludes the provider without the state having to spend the time and resources needed to pursue a formal action. In such an agreement, the provider admits to no wrongdoing but agrees to withdraw from participating in Medicaid. The provider also forfeits the right to appeal if denied reinstatement at a later date. The provider does not, however, face the prospect of losing his or her license to practice because, according to state Medicaid officials, the case is not referred to the...
Page 3 - The OIG also has authority to exclude other individuals or entities if the OIG determines that the particular facts in a case meet its criteria. These so-called 'permissive exclusions" may be based on, for example, submitting excessive claims, license suspensions and revocations, and sanctions imposed by federal or state health agencies. (See the appendix for a complete list of exclusion authorities.' The OIG field offices receive referrals of sanction actions taken by state Medicaid agencies, licensing...
Page 2 - Medicaid is a joint federal-state health program for the poor that expended $159 billion in fiscal year 1995 to provide health care coverage for over 40 million people. Because of its size and complex structure, Medicaid is vulnerable to fraud and abuse. State Medicaid agencies have the primary responsibility to protect the program's financial integrity and to ensure that beneficiaries have access to quality care. This includes ensuring that appropriate safeguards are in place to remove providers...
Page 6 - Currently, about 23 percent of the physicians not allowed to participate in the Illinois Medicaid program have withdrawn in lieu of an action against them. We found that some of the providers who had withdrawn for what appeared to be serious quality of care problems were still able to bill Medicare in Illinois. For example, Medicare paid a podiatrist over $20,000 for services provided to program beneficiaries since he withdrew from the Illinois Medicaid program in August 1995. The podiatrist withdrew...
Page 6 - ... the Secretary of HHS. One of these standards requires MFCUs to report convictions to the OIG. not refer these actions to the state licensing board or the OIG, the providers may continue to provide services like those for which the state sought the provider's removal from Medicaid. As of June 1996, about 23 percent of the physicians not allowed to participate in the Illinois Medicaid program had withdrawn rather than face an adverse action. When we checked on the Medicare status of four providers...
Page 4 - Another weakness we identified in the OIG's process involves inconsistencies among its field offices in how they use their discretionary authority and the types of cases they refer to headquarters. This is especially true in the case of permissive exclusions, where the field offices may decide whether to recommend exclusion. In 1987, the OIG was given expanded discretionary authority to exclude providers nationwide.5 Our work to date, however, indicates that the OIG has not always used its expanded...

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