"Medicare Payments to Excluded and Unlicensed Health Care Providers,"
November 5, 1996
Complete Text of Report is available in PDF format
(1M). Copies can also be obtained by contacting the Office of Public Affairs
This report provides the results of our review of Medicare payments to excluded
and unlicensed health care providers. The objective of our review was to determine
if the Medicare program inappropriately reimbursed individuals or entities who
were excluded from the program or whose license was suspended or revoked by
a State licensing board. Our review was limited to individuals and entities
with a Maryland address at the time of exclusion and individuals whose license
was suspended or revoked by the Maryland Board of Physician Quality Assurance.
the Medicare program has reimbursed 22 percent (6 out of 27) of the excluded
individuals for whom we were able to locate a unique physician/practitioner
identification number (UPIN) during their period of exclusion;
the Medicare program has reimbursed 15 percent (6 out of 40) of the individuals
who had known UPINs with practice locations in the State of Maryland for services
provided while they were unlicensed in the State of Maryland;
individuals who have had their Maryland license suspended or revoked have
relocated to other States and can continue to treat Medicare beneficiaries
in the States they relocated to;
current data bases which contain exclusion and adverse licensure actions
are incomplete and inaccessible; and
a single consolidated source is needed which contains information on all
adverse actions taken against health care providers.
Although nationally the percentage of aberrant health care providers (those
excluded or with a suspended/revoked license) is small, they can endanger the
lives of beneficiaries and should not be allowed to further abuse our health
care system. We recommend that the Health Care Financing Administration (HCFA):
Ensure that Medicare contractors have established adequate controls to preclude
payments to excluded and unlicensed health care providers; expand our data
match nationally to identify payments made to excluded providers; and recover
the payments identified in our review and subsequent data matches from the
excluded and unlicensed providers.
Confirm that its contractors get licensing data from the appropriate State
agencies and that Medicare payments are terminated to unlicensed individuals.
Institute edits in its present and future payment systems to prevent payment
to excluded and unlicensed providers.
Take into consideration our findings as it continues development of the
National Provider System (NPS) and continue to support legislative proposals
to create a comprehensive data base that would capture negative actions on
all health care providers and would be accessible by all interested parties.
Work with the Public Health Service (PHS) to implement section 1921 of the
Social Security Act which would require States to provide information to the
Secretary regarding specified actions (such as revocation or suspension of
a license) taken by the State entity responsible for the licensing of health
care providers. The Secretary is authorized to provide this information to
Federal agencies administering health care programs, State licensing authorities,
State Medicaid agencies, State Medicaid Fraud Control Units, law enforcement
agencies, and other specified entities. It will be necessary to coordinate
this with the implementation of the new adverse action data base created by
Public Law 104-191.
In response to our draft report, HCFA concurred with all of the recommendations.