The Inspector General of the U.S. Department of Health and Human Services (HHS) issued a report earlier this month detailing a study of excluded providers in Medicaid’s managed care network.
The report, entitled “Excluded Providers in Medicaid Managed Care Entities,” was conducted by the Office of Inspector General (OIG), who is authorized to exclude certain providers from participating in federally-funded programs.
According to the OIG, approximately 70% of Medicaid recipients receive services through managed care. However, little was known about how managed care entities (MCE) went about preventing excluded providers from entering their network, or how successful those efforts were.
The report examined 12 MCEs in ten states and found that one-third of the MCEs had excluded providers enrolled in their provider networks.
Ultimately, the OIG recommended that the Centers for Medicare & Medicaid Services (CMS) periodically remind States of their obligation to ensure that no excluded providers receive Medicaid payments. CMS could do this by developing a State Medicaid Director letter to include information from the report on how certain failures led to inclusion of excluded providers, the report stated.