Physicians banned from Medicare still billing state Medicaid programs


The Patient Protection and Affordable Care Act requires states to suspend the billing privileges of most providers who have been kicked out of any state's Medicaid system or the federal Medicare program. However, more than one in five physicians and other providers terminated from the Medicare program or a state Medicaid program are still able to bill Medicaid in another state, according to an analysis of state and federal data by Reuters.

The analysis revealed 1,800 healthcare providers who were banned from billing Medicare or a Medicaid program were still able to bill elsewhere on a given date in 2014. Thirty-two states and the District of Columbia supplied data for the analysis that revealed 269 of the 1,800 providers were paid at least $79 million after their terminations elsewhere, and that could be a low estimate.

"Extrapolating from what could be verified, Medicaid payments to banned providers could easily reach into the hundreds of millions of dollars," the report reads.

To prevent banned providers from billing other government payers, the PPACA required CMS to create a data-sharing system for states to use to identify providers terminated from billing other Medicaid programs and Medicare. However, due to erroneous data being submitted or information not being submitted at all, banned providers slip through the cracks, according to the report.

CMS Deputy Administrator and Director of the Center for Program Integrity Shantanu Agrawal, MD, said CMS is working to rectify the issues with the data-sharing system.

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