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Medicaid Enhanced Provider Enrollment Screenings Have Not Been Fully Implemented

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To bill for items and services provided to beneficiaries, providers must enroll, and periodically revalidate this enrollment, in Medicaid. Effective provider enrollment screening is an important tool in preventing Medicaid fraud. To protect Medicaid against ineligible and fraudulent providers, the Affordable Care Act requires States to screen Medicaid providers according to their risk for fraud, waste, and abuse using enhanced screening procedures. These can include fingerprint-based criminal background checks and site visits. To help States meet the demands of applying enhanced screening to all new and existing providers, the Centers for Medicare & Medicaid Services (CMS) allows States to substitute Medicare or other State Medicaid agency or Children's Health Insurance Program screening results for their own. Ensuring that States screen all providers in accordance with the new requirements is vital to protecting Medicaid, especially as it grows to serve more beneficiaries.


To determine the extent to which States have screened high- and moderate-risk providers using risk-based screening, we surveyed States and requested data about their progress as of August 2014. We also asked States whether they used screening results from Medicare or other State Medicaid agencies as substitutes for their own activities. In addition, we asked States to provide data on the number of new and existing high- and moderate-risk providers requiring screening.


State implementation of risk-based screening is incomplete. Most States reported not having fingerprint-based criminal background checks while waiting for the requirement to take effect. Although CMS did not initially require States to conduct these checks, pending additional guidance, CMS did issue this guidance in June 2015, albeit more than 4 years after the other enhanced screening activities went into effect. In addition, 11 States reported that they have not implemented site visits. Meanwhile, most States reported challenges and concerns regarding substitution of screening results from Medicare or other States for their own. These included difficulties accessing external screening data and ensuring the quality of other State and/or Medicare screening efforts. Some States that did not have all screening activities in place still enrolled and revalidated thousands of providers categorized as posing a high or moderate risk to Medicaid. Finally, 14 States reported that they would not finish revalidating existing high- and moderate risk providers by the September 2016 deadline.


To ensure full implementation of Medicaid enhanced provider screening, we recommend that CMS (1) assist States in implementing fingerprint based criminal background checks for all high risk providers, and (2) assist States in overcoming challenges in conducting site visits. To facilitate substitution of screening results and minimize variation between Medicare and Medicaid, we recommend that CMS (3) enable States to substitute Medicare screening data by ensuring the accessibility and quality of Medicare data, (4) develop a central system where States can submit and access screening results from other States, and (5) strengthen minimum standards for fingerprint-based criminal background checks and site visits. Finally, to ensure that States conduct enhanced screening of existing Medicaid providers, we recommend that CMS (6) work with States to develop a plan to complete their revalidation screening in a timely way. CMS concurred with all six of our recommendations.