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FRAUD/ABUSE


1. Exclusion – According to a 4/29/15 special Investigative Report printed by Reuter, many physicians and other healthcare providers who, because of wrongdoing, have been excluded from participation in Medicare and/or a state Medicaid’s program, continue to operate in and bill to another state Medicaid program without detection. According to the article, Reuters found 1,800 banned providers that were still able to bill elsewhere on a given date in 2014. The problem was originally caused by the CMS data sharing system which has now been replaced with an Excel file that is updated every two weeks. The article also points out that every state has its own Medicaid rules and do not have to exclude a provider banned from Medicare unless the reason for termination falls under the State’s definition of “for cause”.