ACA Fraud Protection Rule Slashes Thousands of Ineligible Providers From Medicaid

Over 65,000 ineligible providers have been culled from the Medicaid program due to a component of the Affordable Care Act that requires periodic recertification of eligibility, according to Modern Healthcare.

The measure, which was meant to prevent fraud and inefficiency, called for providers that enrolled in Medicaid before March 2011 to send “revalidation notices” to CMS to prove their eligibility for reimbursement. Failure to submit a notice by September 25, 2016, meant the provider could be scrubbed from the state Medicaid rolls.

Some common reasons for ineligibility were that they were no longer located in that state, they only enrolled a single patient, or they quit the program. Many of those who left voluntarily said that low reimbursement rates contributed to that decision, the Modern Healthcare article reported.

Another roadblock was that some of the letters notifying providers of the recertification requirement could not be delivered, as their addresses in the Medicaid system were outdated or incorrect. A survey in October found that databases for Medicare Advantage, another CMS program, were rife with inaccuracies, with almost 46% of listings containing errors.

The move comes as CMS has been scrutinized for inefficiencies and waste. In a hearing last month, Vicki Robinson of the Office of the Inspector General in HHS testified that her office had found a number of vulnerabilities in eligibility verification protocols and federal payment controls within CMS. She could not answer lawmakers’ questions about whether the resulting fraud and waste had caused consumers’ premiums to rise.

Some advocates worry that these efforts to control spending and prevent abuse disregard the need to ensure beneficiaries have adequate provider options. According to the Modern Healthcare article, a spokesman for the Texas Medical Association voiced concerns that the move could “jeopardize patient access to care given concerns about network adequacy” in a state that had almost 10% of its Medicaid providers wiped from the program by this rule.