Medicare Billing and the Revolving Door

In April, Yahoo News reported providers who were "Banned from Medicare. Still Billing Medicaid." They cite examples of physicians who billed for services that were not rendered or who "took kickbacks." The result was that the providers were "kicked out" of a particular "state's Medicaid system, or the Medicare system, and then showed up being paid by some other state's "Medicaid health insurance program." The story is not going away, and was in the news again in May.

The report says that the Affordable Care Act "requires that states suspend the billing privileges of most providers who have been terminated or revoked by another state or Medicare." The study cited in the story found that about 20% of those "prohibited from billing Medicare are still able to bill state Medicaid programs." 

The volume of payments was not inconsequential. Those on the list of studied "revoked providers" were paid "a combined total of at least $874,000 while revoked." The article says that data could extrapolate to "Medicaid payments to banned providers" which "could easily reach into the hundreds of millions of dollars."

The article cites examples of efforts by various states to recover funds from banned providers. Minnesota is seeking about one-half million dollars, Nevada about half that. 

There is supposed to be an effort to share data in a more meaningful manner. The Centers for Medicare and Medicaid Services (CMS), the folks who have been responsible for the approval of Medicare set-aside approval in workers' compensation settlements, is "to set up a data-sharing system that would allow states to identify providers terminated" by other programs or jurisdictions. 

CMS concedes that their new system "roll out" was less than stellar. It abandoned the effort in "early 2014" because "several states were unable to access it for at least four months." They have instead begun providing "an Excel file updated every two weeks" to allow some modicum of data sharing among the states. 

The article describes how each state is permitted have its own Medicaid rules, and definitions of the reason for banning a doctor might be characterized in a way that would alert another state not to reimburse, but might not. There will be interpretation and definitional issues.

CMS assures that it is "working to harmonize states' interpretations" regarding provider termination. It concedes that interpretation differences remain. It seems to concede that the data-sharing effort has not yet been all that it can be. 

There are efforts to stop the abuse of Medicare and Medicaid. Anyone that has settled a case in the last ten years knows that CMS can be somewhat hard to deal with, and their mandate has been to protect Medicare's interest. The goal of that process has been to assure that costs for injuries are not inappropriately shifted to these federal programs.  

In the digital age in which we live, it is difficult to understand why an agency of CMS' scope cannot program a computer to provide accurate data-sharing about providers which have been determined ineligible for payments. This should not be hard to define, standardize, collect and distribute. There need not be multiple variables. 

Whether for too many speeding tickets, reckless driving, or otherwise, virtually any state can tell what it needs to know about my driving record, revoked or not? The provider database could provide the same information, eligible or not? Certainly it could take some time to provide more information, as to when and how deemed ineligible. but eligible or not is a very simple question. 

If it is too large a nut to crack, perhaps we should start with a central system under CMS that would exchange data among a "starter set" of states. Then additional states could be brought into the fold over the course of months until it is seamless, national and integrated?

Perhaps states should begin to require providers to certify in order to receive Medicaid payments? Something like "under penalty of perjury, I certify that I have never been deemed ineligible for reimbursement by Medicare or any state Medicaid program." Perhaps some potential of criminal prosecution would help.

The inability of CMS, an agency of extraordinary magnitude, to develop and deploy a database of this importance is not encouraging. It is hoped that better news is coming soon on this front. Perhaps in the meantime, the states can figure out how to stop or at least slow the revolving door?