Is Exclusion Screening even possible?
The U.S. Government Accountability Office has recently released the results of a study conducted in order to gauge the reliability, uniformity, and exhaustibility of exclusion databases available to healthcare providers. Considering that Medicaid remains highly susceptible to fraud and abuse, the U.S. government has long called for strict exclusion screening. Such screening—primarily focused on excluding individuals and entities proven to have committed fraud and abuse of public healthcare funds and their beneficiaries—is deemed to be the first step in ensuring that government funded healthcare programs are spared from improper payments.
The Department of Health Services’ Office of Inspector General maintains the List of Excluded Individuals and Entities (LEIE), which is updated monthly and regarded as the definitive list of exclusions. Moreover, other lists exist for cross-referencing, such as that provided by the System for Award Management (SAM), and those provided by respective states. This is where complications arise. Considering different states oftentimes function under their very own federal statutes, and maintain their very own lists—with 38 states currently maintaining separate lists of exclusions, 12 states short of the ideal—data reliability and exhaustibility is, at times, compromised. This is the very reason why the GAO study was conducted.
The GAO examined managed care providers in order to learn about the experiences of states and plans after using federal databases for screening, and how these states and plans share their collected data pertaining to provider eligibility.
The sample included officials from 10 states chosen based on geography and enrollment, as well as 16 plans representatives operating within these states. Interviews were conducted alongside extensive review of state-run Medicaid program websites and plan contracts, relevant federal laws, regulations, and guidance.
After extensive research, the GAO saw significant challenges faced by selected states and managed care plans in terms of provider screening.
Some of the most striking findings include:
- Fragmented information across 22 databases from 15 different federal agencies was used for screening providers. These included databases not recognized by the Centers for Medicare & Medicaid Services (CMS).
- Current stats on improper payments and the research sample’s employed screening databases beyond those recognized by the CMS suggests that the latter may have failed at identifying all reliable sources of information about ineligible providers that could help states and plans hit objectives.
- Screening efforts are compromised by fragmented information from multiple and disparate federal databases. Challenges include: accessing certain databases, such as the Social Security Administration’s Death Master File; conducting and confirming matches across databases. These challenges have yet to be dealt with by the CMS.
- Sample states operate under disparate practices in relation to making ineligible providers data open to the public.
“Although CMS has issued guidance encouraging states to share data on ineligible providers through its Medicaid provider termination notification system, doing so is optional, not all states are using the list, and it is not available to Medicaid managed care plans. Moreover, CMS has not provided states with guidance on other ways to share their data on ineligible providers or how to access other states’ data on ineligible providers. “
After careful examination of its findings, and with the Health and Human Services’ (HHS) approval, the GAO recommends:
- Consideration of additional databases for screening.
- Collaboration with the Social Security Administration to improve access to the Death Master File.
- Coordination with other agencies to develop a common identifier across databases.
- Provide state Medicaid programs with guidance that establishes expectations and best practices on sharing provider screening data among states and plans.
The existence of these fragmented databases will take some time to be completely resolved. This resolution entails drastic changes in operational and statutory procedures in order to facilitate easy and reliable cross-referencing between databases recognized by all states and relevant plans.
Meanwhile, alternatives exist. For instance, private companies offer comprehensive screening tools and procedures to providers who hope to be consistently on the right side of the law. These private companies, such as Streamline Verify, are a one-stop-shop committed to top-notch provider compliance in behalf of interested parties.