CMS System for Sharing Information About Terminated Providers Needs Improvement

WHY WE DID THIS STUDY

The Patient Protection and Affordable Care Act (ACA) requires the Centers for Medicare & Medicaid Services (CMS) to establish a process for sharing information about terminated providers. To meet this requirement, CMS established a Web-based portal, the Medicaid and Children's Health Insurance Program State Information Sharing System (MCSIS). Sharing terminated provider data among States prevents terminated providers in one State from enrolling in another State. CMS and State agencies can submit information about providers that meet CMS's criteria for having been terminated "for cause" from Medicare, Medicaid, or the Children's Health Insurance Program (CHIP). State Medicaid agencies can use these data to identify these providers and subsequently terminate them from their Medicaid programs as required under another section of the ACA. In November 2013, subsequent to the timeframe we examined for this study, CMS revised its process for sharing information about terminated providers. The findings and recommendations in this report remain relevant to the new process.

HOW WE DID THIS STUDY

We examined all provider records contained in MCSIS as of June 1, 2013. We (1) determined the extent to which MCSIS contained records submitted by CMS and State Medicaid agencies; (2) identified records that did not meet CMS criteria for reporting providers terminated "for cause" from Medicare, Medicaid, or CHIP; and (3) assessed whether records had complete identifying information about providers, including National Provider Identifiers (NPIs), provider types, and provider addresses.

WHAT WE FOUND

As of June 1, 2013, MCSIS contained records on terminated providers submitted by CMS and 33 State Medicaid agencies and did not contain records from the remaining State Medicaid agencies. Contrary to CMS guidance, about one-third of the 6,439 records in MCSIS did not relate to providers terminated "for cause." Over half of MCSIS records did not contain NPIs, a critical data element for accurately identifying providers. Additionally, one-third of MCSIS records did not identify the provider types and one quarter had no provider addresses.

WHAT WE RECOMMEND

Our findings suggest that CMS's process for sharing information on terminated providers needs improvement to make it more useful to State Medicaid agencies in identifying providers that must be terminated pursuant to Federal law because they were terminated "for cause" by Medicare, Medicaid, or CHIP. Therefore, we recommend that CMS (1) require each State Medicaid agency to report all terminated providers, (2) ensure that the shared information contains only records that meet CMS's criteria for inclusion, and (3) take action to improve the completeness of records shared through the process. CMS concurred with all recommendations.