Excluded Individuals Employed by Providers Enrolled in Medicaid Managed Care Entities

WHY WE DID THIS STUDY

OIG is authorized to exclude certain individuals and entities (providers) from participating in federally funded health care programs, such as Medicaid managed care. These programs are generally prohibited from paying for any items or services furnished, ordered, or prescribed by an excluded provider or paying anyone who contracts with an excluded provider. In Medicaid managed care, States contract with managed care entities (MCE) to provide healthcare services to enrolled beneficiaries. The managed care entities create and manage networks of providers who deliver healthcare services to the enrolled beneficiaries. Since the providers in the Medicaid managed care networks are not under direct oversight by the States, we wanted to determine if the provider networks are vulnerable to excluded providers.

HOW WE DID THIS STUDY

This is the second of two evaluations related to excluded providers in Medicaid managed care. In the prior study, entitled Excluded Providers in Medicaid Managed Care Entities (OEI 07 09 00630), we compared the provider networks of 12 selected MCEs to the List of Excluded Individuals and Entities (LEIE) to identify excluded providers. In the current study, we selected a stratified random sample of 500 hospitals, nursing facilities, home health agencies, and pharmacies from the population of providers enrolled in the 12 MCEs. From each of the 500 sampled providers, we collected rosters of employees in 2011, and responses to a survey on the safeguards they used to ensure that excluded individuals are not employed. We compared the employee rosters to the LEIE to identify excluded individuals.

WHAT WE FOUND

Of the 248,869 individuals listed on the employee rosters requested from sampled providers, we identified 16 individuals who were excluded among the employees of 14 sampled providers. Incorrect names and failure of contractors to follow procedures contributed to the employment of the excluded individuals. Most providers reported using a variety of safeguards to ensure they do not employ excluded individuals, but identified costs and resource burdens as challenges in executing those safeguards. Seven percent of providers in the 12 selected MCEs do not check the exclusions status of their employees; most of these providers lacked knowledge regarding exclusions.

This report does not contain recommendations.