Figuring out who can bill Medicare and Medicaid, and who can't

Published: 13:24 GMT, 29 April 2015 | Updated: 13:24 GMT, 29 April 2015

By M.B. Pell and Kristina Cooke

April 29 (Reuters) - To determine how many healthcare providers were banned from Medicare or a state Medicaid program while still allowed to bill Medicaid in another state, Reuters compared states' lists of approved providers against lists of providers terminated by other states or Medicare on a specific date in 2014.

In response to open-records requests, all states and the District of Columbia supplied approved-provider lists. Only 23 states supplied terminated-provider lists, as did the Centers for Medicare and Medicaid Services, the federal agency that administers Medicare, and the U.S. Department of Health and Human Services Office of the Inspector General.

To avoid false matches, only providers with a National Provider Identifier number were included. About 55 percent of revoked or terminated providers were correctly coded with that identifier.

Reuters made every effort to include only those providers terminated "for cause" - the standard in the Affordable Care Act that requires states to follow suit and terminate a provider. CMS defines "for cause" as "terminations

based upon fraud, integrity, or quality."

Providers that were terminated, but not "for cause," were removed from the analysis when: the termination resulted from a lapsed license while the provider continued to practice fully licensed in another state; the provider received a waiver because of a shortage of the services provided; or a providers' revocation had been overturned on appeal.

Some providers were kept in the analysis even though they hadn't been terminated for cause: dead doctors (because their provider numbers can still be used for fraudulent purposes by others); and providers revoked from one part of Medicare but still allowed to bill another.

In some cases, the data gave only a vague reason for the revocation. Reuters included those providers unless a state or another source provided a reason not to.

Ultimately, the analysis yielded 1,800 providers terminated for cause or falling under one of the exceptions Reuters established.

Only thirty-two states and Washington, D.C. provided billing information on the 1,800 providers. Most of the rest of the states asked for between $150 and $12,000 for the information.

(Edited by John Blanton)


Category: Insurance

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