(WASHINGTON, DC) – On Wednesday, the House of Representatives approved a bipartisan Medicaid reform bill authored by Congressmen Larry Bucshon, M.D. (R-IN), Peter Welch (D-VT), and G.K. Butterfield (D-NC). H.R. 3716, the Ensuring Access to Quality Medicaid Providers Act, strengthens the Medicaid program and saves taxpayer dollars by ridding the program of bad actors. Specifically, the bill ensures that providers terminated from Medicare or a state Medicaid program for reasons of fraud, integrity, or quality, are terminated from all other state Medicaid programs.
“This bill strengthens Medicaid and improves patient access to quality care by ridding the program of fraudulent actors who seek to take advantage of the most vulnerable patients and scam taxpayers. Our bipartisan bill ends waste, fraud, and abuse in the Medicaid program saving taxpayers an estimated $15 million. As a physician who spent my career taking care of patients, I understand how critical it is to protect those suffering in a broken system. I urge the Senate to act immediately so this bill can be signed into law.â€Â Congressman Larry Bucshon, M.D. (R-IN)
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“If a provider is terminated from Medicaid for fraudulent practices in New Hampshire, we must ensure that provider is prohibited from crossing state lines and setting up shop across the border in Vermont or elsewhere. This threat of Medicaid fraud remains because of a lack of consistent reporting and communication between states. I’m pleased the House passed this bipartisan legislation to prevent bad actors from taking advantage of Medicaid beneficiaries and the American taxpayer. It’s just common sense. The Senate should pass this bill without delay and send this bipartisan bill to the President.â€Congressman Peter Welch (D-VT)
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“This important, bipartisan bill will safeguard American taxpayers and bring greater integrity to our federal and state healthcare programs. More than 72 million Americans rely on the Medicaid program including 75 percent of children who live in poverty. This legislation is important to ensuring we are making the best use of Medicaid funds and is based on recommendations from HHS and CMS reports.â€Â Congressman G. K. Butterfield (D-NC)
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“Today’s vote is an important step in strengthening Medicaid for the most vulnerable. It’s also a great accomplishment in our current climate – a bipartisan bill reforming Medicaid. The committee has been working hard to find ways to improve the program and ensure it’s working. I applaud Dr. Bucshon and Rep. Welch for bringing this commonsense solution to light.” Energy and Commerce Chairman Fred Upton (R-MI)
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In a statement, the White House announced its support for H.R. 3716 saying, “The Administration supports House passage of H.R. 3716 because it improves program integrity for Medicaid and the Children’s Health Insurance Program (CHIP).â€
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THE PROBLEM:
State Medicaid programs have been required since 2011 to terminate a provider’s participation in Medicaid if that provider is terminated for reasons of fraud, integrity, or quality from another State Medicaid program. Despite this requirement, the Department of Health and Human Services (HHS) Office of Inspector General (OIG) found continued participation from such providers in other states’ Medicaid programs.  Specifically, the HHS OIG found that 12 percent of terminated providers (295 of the 2,539 providers) participated Medicaid programs as of January 1, 2012, after the same provider was terminated for cause from another State Medicaid program. Further, 172 of the 295 providers continued participation in Medicaid as late as January 2014, more than 2 years after being terminated for cause from another State program.  These Medicaid programs paid $7.4 million to 94 providers for services performed after each provider’s termination for cause by the initial State.
The HHS OIG noted challenges faced by states in implementing the requirement as:
- The lack of a comprehensive centralized data source that identifies providers terminated for reasons of fraud, integrity, or quality.
- The lack of uniform terminology in existing data sources regarding the reasons for provider terminations.
- Challenges related to excluding providers participating in managed care since those providers may not be enrolled with the state Medicaid agency.
THE SOLUTION:
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H.R. 3716, the Ensuring Access to Quality Medicaid Providers Act, ensures that providers terminated from Medicare or a state Medicaid program for reasons of fraud, integrity, or quality, are also terminated from all other state Medicaid programs. Specifically the bill:
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- Requires state Medicaid and CHIP programs to report providers terminated for reasons of fraud, integrity, or quality to CMS within 21 business days.
- Requires CMS to include state-reported provider terminations and Medicare provider terminations in its Termination Notification Database or equivalent system within 21 business days.
- Requires state Medicaid and CHIP managed care contracts to include a provision that providers terminated for reasons of fraud, integrity, or quality from Medicare, Medicaid or CHIP programs be terminated from participation in Medicaid and CHIP managed care provider networks.
- Requires providers serving Medicaid beneficiaries to be enrolled with the State Medicaid agency. This provision is to ensure a state has a comprehensive list of providers serving Medicaid patients in the state and thus, know if there is a provider that was terminated from Medicare or another state program that also needs to be terminated from participation in that state.
- Requires CMS to develop a uniform terminology for classifying the reasons for terminations.
- Requires states to pay back (and CMS to recoup) the federal portion of Medicaid/CHIP payments made to providers for services performed more than 60 days after the provider’s termination was included in the CMS Termination Notification Database.
- Requires HHS OIG to evaluate federal and state implementation of these new requirements.
SAVING $15 MILLION IN TAXPAYER DOLLRS:
According to the Congressional Budget Office, H.R. 3716 will reduce federal outlays $15 million over the 10 year budget window, by eliminating Medicaid payments to fraudulent providers. H.R. 3716 would also save State Medicaid programs several million dollars over the same timeframe, but CBO does not estimate state-specific savings.