Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
P T F  
R OVIDERS  ERMINATED  ROM 
 
O S M P
NE  TATE  EDICAID  ROGRAM 
 
CO  NTINUED PARTICIPATING IN  
 
O S  
THER  TATES 
 
 
Suzanne Murrin  
Deputy Inspector General for 
Evaluation and Inspections 
 
August 2015 
OEI-06-12-00030   
   
EXECUTIVE SUMMARY:  PROVIDERS TERMINATED FROM ONE STATE 
MEDICAID PROGRAM CONTINUED PARTICIPATING IN OTHER STATES  
OEI-06-12-00030  
 
WHY WE DID THIS STUDY 
Prior to passage of the Patient Protection and Affordable Care Act (ACA), if a State 
terminated a providers participation in its Medicaid program, the provider could 
potentially participate in another States Medicaid program, leaving the second States 
program vulnerable to fraud, waste, or abuse committed by that provider. To prevent this 
from happening, the ACA requires States to terminate a providers participation in their 
respective State Medicaid programs if that provider is terminated for cause (i.e., for 
reasons of fraud, integrity, or quality) from another State Medicaid program.  In 2014, the 
Office of the Inspector General (OIG) published a report that recommended 
improvements to address weaknesses in CMSs process for sharing termination 
information among the States.  This study builds on the prior report by determining 
whether Medicaid providers that States reported as having been terminated for cause 
continued to participate in Medicaid in other States. 
 
HOW WE DID THIS STUDY 
Because the termination data collected through CMSs process was not comprehensive 
and complete, we went directly to each State Medicaid agency and requested rosters of  
all individual Medicaid providers terminated in 2011 for cause.  We also requested 
rosters of individual Medicaid providers participating in Medicaid fee-for-service and 
managed care on January 1, 2012.  We compared these State-submitted rosters to 
determine if providers had been terminated.  In January 2014, we followed up with State 
Medicaid agencies to determine if and when each providers participation in Medicaid 
ended, and the amount that Medicaid paid each provider for services performed after the 
providers termination for cause from another State program.  We obtained information 
from State Medicaid agency staff about challenges in implementing the termination 
requirement.  
 
WHAT WE FOUND 
Despite the ACA requirement for States to terminate any providers already terminated for 
cause in another State, we found continued participation from such providers in other 
States Medicaid programs.  Specifically, we found that 12 percent of providers (295 of 
2,539) terminated for cause in 2011 were still participating in other States Medicaid 
programs in January 2012, and many continued to participate as late as January 2014.  
These Medicaid programs paid $7.4 million to 94 providers for services performed after 
each providers termination for cause by the initial State.  The challenges that States face 
in meeting the intent of the ACA legislation include not having a comprehensive data 
source for identifying all terminations for cause and difficulty differentiating such 
terminations from other administrative actions that a State reports.  Further complicating 
States ability to terminate providers is that, of the 41 States that used managed care to 
deliver Medicaid services, 25 States did not require providers who participated via 
managed care to be directly enrolled with the State Medicaid agency.  If a State has not 
directly enrolled a provider, it cannot terminate that provider, and it may not even be 
   
   
aware that the provider is participating in its Medicaid program.  Also challenging for 
some States is their misunderstanding that if a provider has an active license from the  
relevant State board, the State Medicaid agency should defer to the judgment of that 
board and not terminate the provider for cause.  
 
WHAT WE RECOMMEND  
In March 2014, OIG recommended that CMS require State Medicaid agencies to report 
all terminations for cause. We  reiterate this prior recommendation as we found the lack of 
a comprehensive data source of providers terminated for cause creates a challenge for 
State Medicaid agencies.  To address the remaining issues identified in this report, we 
recommend that CMS (1) work with States to develop uniform terminology to clearly 
denote terminations for cause, (2) require that State Medicaid programs enroll all 
providers participating in Medicaid managed care, and (3) furnish guidance to State 
agencies that termination is not contingent on the providers active licensure status.      
CMS concurred with our recommendations. 
   
TABLE OF CONTENTS   
 
Objectives ....................................................................................................1 

Background..................................................................................................1 

Methodology................................................................................................4 

Findings........................................................................................................7 

Twelve percent of providers who were reported as terminated for 

cause from State Medicaid programs continued participating in 

Medicaid in other States ..................................................................7 

Medicaid paid approximately $7.4 million to providers for  

services performed after the providers had each been terminated 

for cause in 2011 by another State Medicaid program ...................7 

State Medicaid agencies faced challenges in ensuring that   

providers terminated for cause from Medicaid in other States       

did not continue participating in Medicaid in their own States .......8 

Conclusion and Recommendations ............................................................12 

Agency Comments and Office of Inspector General Response .....14 

Appendixes ................................................................................................15 

A: 	Detailed Methodology............................................................15 

B: 	Providers Reported by State Medicaid Agencies as Terminated 

For Cause................................................................................17 

C: 	Providers Reported by State Medicaid Agencies as Terminated 

For Cause and Still Participating in Other States ...................20 

D: 	 Payments to Providers Reported As Terminated For Cause ...23 

E: 	Data Sources Used by State Medicaid Agencies ....................25 

F: 	Reasons for Terminations For Cause ......................................26 

G: 	State Medicaid Agency Enrollment of Medicaid Managed 

Care Providers .......................................................................27 

H: Agency Comments  .................................................................29 

Acknowledgments......................................................................................31 

 
   
   
OBJECTIVES 
1. 	  To determine the extent to which individual providers who were 
terminated for cause from one or more State Medicaid programs 
continued participating in Medicaid in other States. 
2. 	  To determine the amount Medicaid paid to such providers, if any, for 
services performed after their terminations for cause in other States. 
3. 	  To describe challenges faced by State Medicaid agencies in ensuring 
that providers terminated for cause from Medicaid do not continue 
participating in Medicaid in other States. 
BACKGROUND 
The Patient Protection and Affordable Care Act1 (ACA) provided the 
Centers for Medicare & Medicaid Services (CMS) and State Medicaid 
agencies with new tools to strategically reduce the risk of fraud, waste, 
and abuse in Medicare, Medicaid, and the Childrens Health Insurance 
Program (CHIP).2  One of these tools relates to providers who were 
terminated from Medicare or from  State Medicaid programs for program  
integrity reasons.  Before the ACA was passed, if one State terminated the 
participation of a provider from its Medicaid program, the provider could 
potentially enroll in or continue participation in another States Medicaid 
program, leaving the second States program vulnerable to potential fraud, 
waste, and abuse committed by that provider.3  Section 6501 of the ACA  
requires that effective January 1, 2011, each State must terminate the 
participation of a provider from its State Medicaid program if that 
providers participation was terminated from Medicare or from another 
State Medicaid program.4  This requirement strengthens Medicaid 
program integrity across States, so that providers found to warrant 
termination in one State may not continue to treat (or begin to treat) 
Medicaid beneficiaries in another State and receive Medicaid payments 
for doing so. 
Regulation and guidance define three terms that are critical to 
understanding section 6501 of the ACA:  provider, termination, and 
for cause. The term provider refers to individuals or entities 
____________________________________________________________ 
1  P.L.  No. 111-148  6501 (Mar. 23, 2010),  as  amended by  the Health  Care  and 
Education Reconciliation Act  of 2010, P.L. No. 111-152  (Mar. 30, 2010).   
2 CMS, Center for Program Integrity, New Strategic Direction and Key  Antifraud 
Activities, November  3,  2011. Accessed at https://www.cms.gov/Medicare-Medicaid-
Coordination/Fraud-Prevention/MedicaidIntegrityProgram/downloads/cpiinitiatives.pdf   
on  February 7, 2013. 
 
3 76 Fed. Reg. 5862, 5943 (Feb. 2, 2011). 

4   ACA  6501, Social  Security  Act  1902(a)(39),  42 U.S.C.  1396a(a).  

Providers Terminated From One State Medicaid Program Continued Participating in Other States (OEI-06-12-00030)   1 
   
   
furnishing services to Medicaid beneficiaries under fee-for-service or  
managed care arrangements.5  A termination occurs when the Medicare, 
Medicaid, or Childrens Health Insurance Program (CHIP) programs 
revoke a providers billing privileges for cause, the provider exhausts all 
appeal rights, and there is no expectation that the revocation of billing 
privileges is temporary.6, 7 As defined by the Centers for Medicare & 
Medicaid Services (CMS), terminations for cause are terminations for 
reasons of fraud, integrity, or quality.8  Terminations for cause do not 
include cases in which a program terminates a provider as a result of 
billing inactivity or those in which a provider voluntarily ends 
participation in the program, except when a provider takes this voluntary 
action to avoid a sanction, such as revocation or termination.9  
In practical terms, after a State terminates a provider for cause, other 
States implementation of section 6501 of the ACA involves three steps:  
learning, identifying, and acting. First, a State agency must learn about 
providers who were terminated for cause from Medicare or other State 
Medicaid or CHIP programs.  Second, the agency must identify whether 
any of those terminated providers are participating in the States Medicaid 
program, taking steps to verify a providers identity, if it is in question.  
Third, the agency must act appropriately to terminate the providers  
participation in its own State Medicaid program.  (See Figure 1.) 
 
 
 
____________________________________________________________ 
5 Pursuant to  42 CFR  400.203, provider means either of the following:  (1) for the  
 
fee-for-service program, any individual or entity furnishing  Medicaid services under an 
 
agreement with the Medicaid agency; (2) for the managed care program, any individual 
 
or entity that is engaged in the delivery of health care services and is authorized to  do so 

by the State in  which it delivers the services. 

6 42 CFR   455.101, definition  of Termination, (13). 

7 In  guidance, CMS noted that  terminations differ from exclusions.  Generally, 

exclusion from participation in a federal health care program, including Medicare, 

Medicaid, and CHIP is a penalty imposed on providers and suppliers by the Departments 

Office of Inspector General (HHS-OIG).  Individuals and entities may be excluded from  

participating  in federal health care programs for misconduct ranging from fraud
  
convictions to patient abuse to  defaulting on health education loans. CMS, CPI-B 11-05. 
 
8 42 CFR   455.101, definition  of Termination, (3);  CMS, CPI-B 12-02,  Affordable 

Care Act Program Integrity  ProvisionsGuidance to StatesSection 6501Termination of  
Provider participation under Medicaid if  Terminated  under  Medicare or other  State 
Plan, January 20, 2012.  
9 CMS, CPI-B 11-05, ACA Program Integrity  ProvisionsGuidance to States 
Section 6501Termination of Provider Participation Under Medicaid if Terminated  
Under Medicare or Other State Plan, May 31, 2011.    
Providers Terminated From One State Medicaid Program Continued Participating in Other States (OEI-06-12-00030)   2 
   
   
 
Figure 1. 
Note: State A refers to the State that initiates a providers termination for cause. State B refers to any  other State where this 
 
provider is currently providing services or to where the provider could move. 
CMS Processes Were Ineffective for Sharing Information about 
Providers Terminated For Cause 
To facilitate learning about termination actions by Medicare and by other  
State Medicaid agencies, section 6401(b)(2) of the ACA requires CMS to 
establish a process to make available to these agencies information about 
providers terminated for cause from the Medicare, Medicaid, and CHIP  
programs.10  To address this requirement, CMS established a data-sharing 
process that used a secure Web-based portal.  This process allowed State 
Medicaid agencies to voluntarily report providers whom the agencies  
terminated for cause from their programs and to retrieve information about 
providers who were terminated for cause by Medicaid programs in other 
States.11   
 ____________________________________________________________ 
10 Most of the available data sources are designed for purposes other than identifying  
providers terminated for cause.
  
11 This  Web-based portal was the Medicaid and CHIP State Information Sharing System 
 
(MCSIS).  In February 2014, CMS replaced MCSIS with  the Termination Notification 
 
database. 

Providers Terminated From One State Medicaid Program Continued Participating in Other States (OEI-06-12-00030)   3 
   
   
However, a March 2014 report by the Office of Inspector General (OIG) 
found that CMSs process to share termination information among the 
States needed improvements.12  Three problems undermined the 
effectiveness of the process established by CMS:  (1) many State 
Medicaid agencies did not report any  terminations for cause; (2) of those 
reported, many records did not relate to providers terminated for cause; 
and (3) many records did not contain sufficient informationsuch as the 
National Provider Identifier (NPI) or a Social Security Number (SSN)to 
confidently identify the providers who were terminated for cause.  OIG 
recommended that CMS make improvements to its process and require 
that State Medicaid agencies report all terminations for cause (rather than 
continuing with the prior voluntary reporting approach) and take action to 
improve the completeness of termination records.13 CMS concurred with 
each of our recommendations and reported changes that it had underway 
and future plans for its process for sharing information on terminated 
providers. For example, CMS implemented procedures intended to 
improve the completeness of the records, such as requiring States to 
submit a copy of the Medicaid termination letter issued to the provider as 
well as information such as the providers NPI or SSN.14   Additionally,  
CMS reported that it reviews each termination to assure that it meets CMS 
criteria for inclusion in the Termination Notification database.15  
METHODOLOGY 
This report examines individual providers (hereafter referred to as 
providers) who were participating in Medicaid fee-for-service and 
managed care in all 50 States, the District of Columbia, and the five 
territories (hereafter referred to collectively as States).16,17 Although 
section 6501 applies to Medicare, Medicaid and CHIP providers, we 
____________________________________________________________ 
12 OIG,  CMSs Process for Sharing Information About Terminated  Providers Needs 
 
Improvement, OEI-06-12-00031,    March  2014. 

13 Ibid. 

14 CMS, Email to  State Program Integrity Directors, February 7, 2014. 

15 OIG,  CMSs Process for Sharing Information About Terminated  Providers Needs 
 
Improvement, OEI-06-12-00031, March 2014.  See CMS Response, p. 22. 

16 The study includes individual business  owners, employees, and caretakers  who were  
reported as terminated for cause and  who  were  not allowed to bill for services performed  
for Medicaid beneficiaries.  It does not include provider  organizations (nursing homes, 
home health agencies, ambulatory surgical centers, etc.). 
17 The five territories are American Samoa, Guam, the Northern Mariana Islands,    
Puerto Rico, and the Virgin Islands. 
Providers Terminated From One State Medicaid Program Continued Participating in Other States (OEI-06-12-00030)   4 
   
   
limited this study to individual Medicaid providers.18 (See Appendix A for 
a detailed methodology.)   
To perform this review, we obtained from each State agency a roster of all 
providers (fee-for-service and managed care) who were participating in 
that States Medicaid program as of January 1, 2012.  We also obtained 
from each State agency a roster of all providers (fee-for-service and 
managed care) who were terminated for cause from the States Medicaid 
program during 2011.  We based our report findings on a review of 
2,539 unique individual providers who were reported as terminated for 
cause from State Medicaid programs during 2011.19 (See Appendix B for 
detailed information about providers reported as terminated for cause in 
2011 from State Medicaid Programs by State and by provider type.) 
For each of the 2,539 providers reported as terminated for cause during 
2011, we examined all other States rosters of providers participating in 
Medicaid as of January 2012. We then followed up with State Medicaid 
agencies in January 2014 to determine whether and when each providers 
participation in Medicaid ended. In response to original terminations that 
occurred very late in 2011, our 2014 followup ensured that we captured 
provider terminations that occurred after the collection of participation 
rosters in January 1, 2012. 
We calculated the frequency and percentage of providers who were 
terminated for cause in 2011 yet were still participating in Medicaid in 
January 2012 and in January 2014. We also obtained data from States and 
calculated the amount that State Medicaid programs paid providers for 
services performed after their terminations for cause from other States 
Medicaid programs through January 2014.   
We contacted State Medicaid agency staff to discuss our data requests and 
to follow up on specific providers. We reviewed additional information 
that agencies provided in their responses to our data request.  We also 
administered a structured questionnaire to State Medicaid agencies.  
Through these efforts, we identified challenges that they encountered in 
complying with section 6501 of the ACA.  
____________________________________________________________ 
18  We  did not include in  our analysis any of the providers whom CMS terminated  for  
cause from  Medicare because the data that  we obtained from CMS regarding  such  
providers were not sufficiently complete for purposes of  our analysis.  We decided  not to 
separately collect data about CHIP providers because of the variation among States in 
how CHIP services are delivered relative to  Medicaidsome States have separate CHIP  
programs, some expanded Medicaid to include CHIP, and some States offer a 
combination of separate CHIP programs and Medicaid expansion that included CHIP.  
19 Twenty-nine providers were reported by more than one State as having been terminated 
for cause.  
Providers Terminated From One State Medicaid Program Continued Participating in Other States (OEI-06-12-00030)   5 
   
   
Limitations 
The analysis and findings presented in this report rely on the information 
submitted to OIG by State Medicaid agencies regarding individual 
providers who were participating in, and were terminated for cause from, 
their Medicaid programs.  We did not verify the completeness or accuracy 
of the data submitted to OIG by State agencies.  For example, although we  
requested that the agencies submit rosters of providers who were 
terminated for cause, it was outside the scope of our methodology to 
verify that each termination submitted by State agencies aligned with the  
definition of termination for cause specified in CMS guidance.   
Our findings may have underestimated the number of providers who 
continued participating in State Medicaid programs after their terminations 
for cause from Medicaid programs in other States and the associated 
Medicaid payments to these providers.  In some instances, records on 
terminated providers did not contain sufficient information for us to make 
a definitive match.  For example, if a State submitted a terminated 
provider record with an SSN but not an NPI, and the same provider 
participated in Medicaid in another State that submitted neither SSN nor 
NPI, our comparison would not identify the provider.  Additionally, the 
records that were sent for 145 terminated providers did not contain any 
data elements needed to determine whether the providers were 
participating in other States. Further, we may have underestimated the 
amount of Medicaid payments made to managed care providers, because 
we did not collect payment data directly from Medicaid managed care 
entities and some States did not report this information.   
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General 
in Integrity and Efficiency. 
   
Providers Terminated From One State Medicaid Program Continued Participating in Other States (OEI-06-12-00030)   6 
   
   
FINDINGS 
Twelve percent of providers who were reported as 
terminated for cause from State Medicaid programs 
continued  participating in Medicaid in other States 
State agencies reported that 295 of the 2,539 providers (12 percent) were 
participating in their Medicaid programs as of January 1, 2012, after the 
same provider was terminated for cause from another State Medicaid 
program.20  Further, 172 of the 295 providers continued their participation 
in Medicaid as late as January 2014, more than 2 years after they were 
terminated for cause from another State program.  (See Appendix C for the 
number of providers who were terminated for cause in 2011 and were still 
participating in Medicaid in 2012, by State and by provider type.)  The 
continued participation of these providers after their terminations for cause 
from other State programs presents a vulnerability to Medicaid.   
State Medicaid programs paid approximately 
$7.4 million to providers for services performed after 
the providers had each been terminated for cause in 
2011 by another State Medicaid program 
Ninety-four of the two hundred ninety-five providers received total 
Medicaid payments of $7,410,568 for services performed after the 
providers had been terminated for cause in 2011 by other States.  Fifteen 
of these providers each received payments totaling $100,000 or more.  
Medicaid paid one provider just over $1 million for services performed 
after the providers termination for cause.  (See Appendix D for payments 
to terminated providers by State and provider type.) 
State agencies reported that they did not make any Medicaid payments to 
the remaining 201 of the 295 providers.21  Nonetheless, it remains 
concerning that these providers continued as participating providers who 
could treat Medicaid beneficiaries. 
   
____________________________________________________________ 
20 The remaining 2,244 providers were not  reported as participating in Medicaid in any  
States as of January 1, 2012. 

21  Among  the 201 providers with no  reported payments after their terminations for cause, 

125 were participating in Medicaid through  managed care.  Thus, it is possible these 

providers were paid by the Medicaid managed care organization, rather than by the State 

agency.   As we have noted, we did not collect payment data directly from Medicaid 

managed care entities and some States did  not report this information to  us. 

Providers Terminated From One State Medicaid Program Continued Participating in Other States (OEI-06-12-00030)   7 
   
   
State Medicaid agencies faced challenges in ensuring 
that providers terminated for cause from Medicaid in 
other States did not continue participating in Medicaid 
in their own States  
We identified significant challenges that can hamper a State Medicaid 
agencys ability to implement the requirement in section 6501 of the ACA 
to terminate the Medicaid participation of providers who were terminated 
for cause by other State Medicaid programs.   
State Medicaid agencies face challenges getting information about 
providers terminated for cause by other State agencies.  These challenges  
consist of (1) not having a comprehensive data source for identifying all 
terminations for cause and (2) differentiating terminations for cause from  
other administrative terminations in the data sources that are available.  
State Medicaid agencies also face challenges terminating providers once 
they learn of a providers termination for cause by another State agency.  
These challenges consist of (1) the inability to terminate providers who are 
participating in Medicaid managed care but are not enrolled by the State 
Medicaid program and (2) a misunderstanding that if a provider has an 
active license from the relevant State licensing board, then the State 
Medicaid agency should defer to the judgment of the State licensing board 
and not terminate the provider for cause. 
The lack of a comprehensive centralized data source that 
identifies providers terminated for cause create challenges for 
State agencies seeking to learn about such providers 
Despite the existence of several potential data sources, to date there has 
been no single source that is comprehensive enough to allow States to 
identify all the fee-for-service and Medicaid managed care providers 
enrolled in State Medicaid programs whose terminations for cause warrant 
action pursuant to section 6501 of the ACA.  Most of the available data 
sources are designed for purposes other than identifying providers 
terminated for cause, and therefore do not attempt to identify all such 
providers. Although the CMS Termination Notification database is 
designed for this purpose, States participation is encouraged, rather than 
required. 
State agencies reported using several strategies to learn about terminated 
providers. One common strategy is to examine existing Federal data 
sources to identify such providers.  (See Appendix E for data sources that 
State Medicaid agencies reported using to learn about terminated 
providers.) Other strategies that State agencies reported using involved 
their checking State Websites and State licensing board rosters, directly 
Providers Terminated From One State Medicaid Program Continued Participating in Other States (OEI-06-12-00030)   8 
   
   
contacting other State Medicaid agencies, and receiving alerts from other 
entities about providers terminated for cause. The drawback to these 
strategies, according to State agencies, is that they can be arduous, time 
consuming, and inconclusive as to whether a State agency learns about all  
Medicaid providers terminated for cause by other States or only a portion 
of such providers. 
Lack of uniform terminology in  existing data sources regarding 
the reasons for provider terminations can create challenges in  
differentiating provider termination status 
The lack of uniform terminology concerning termination reasons in 
existing information sourcessuch as Federal and State databases and 
Web sitescan create challenges for State agencies in identifying 
terminations for cause by other States.  State agencies use a variety of 
terms to describe reasons for provider terminations.  Table 1 lists 
examples of  termination reasons that State agencies submitted to OIG 
about providers terminated for cause in 2011.  As indicated in Table 1, 
most of the termination reasons reference the action taken by the State 
agency (i.e., debarment, exclusion, revocation), rather than the reason for 
the termination (i.e., credentialing violation, policy violation, criminal 
conviction). (See Appendix F for the types of termination reasons that 
State Medicaid agencies submitted to OIG.)   
Table 1:  State Medicaid Agencies Used Many Different Terms 
to Describe Reasons for Terminations 
Termination Reasons  
  Banned     Disciplinary action     Revocation  
  Canceled     Exclusion    Sanction  
  Conviction     Indictment     Suspension  
  Credentialing  violation    Licensure modification    Termination 
  Debarment      
Source:  OIG analysis of Medicaid  termination data (2011).  
In their databases, some State agencies applied the same reason code to 
terminations for cause as they did to terminations for administrative 
reasons. The latter category includes actions such as removing a provider 
from participation in Medicaid because of the providers billing inactivity  
or an inactive license.  Because some State agencies do not distinguish in 
their reporting between terminations for cause and terminations for 
administrative reasons, there is a risk that those agencies could report 
inaccurate information (both to CMS and to other States) about 
terminations of providers.  In turn, this could make other State Medicaid 
agencies reluctant to terminate a provider that such a State reports as 
terminated for cause.  
Providers Terminated From One State Medicaid Program Continued Participating in Other States (OEI-06-12-00030)   9 
   
   
State Medicaid agencies that do not enroll all providers can 
face challenges in identifying their managed care providers 
and terminating Medicaid participation  
Of the 41 States that used managed care in 2012 to deliver Medicaid 
services, 25 States did not require providers who were participating in 
Medicaid managed care to be directly enrolled with their State Medicaid 
agencies.22,23  Of the 295 providers who were reported by States as 
terminated for cause but who continued to participateor began 
participatingin other States, 91 were not directly enrolled in the 
Medicaid programs of the States where they continued or began 
participating.  Rather, they were participating in Medicaid in those States 
via contracts with managed care entities.  (See Appendix G for more 
information on State Medicaid agency enrollment of Medicaid managed 
care providers.) 
When States do not require providers who participate in Medicaid 
managed care to enroll directly in their Medicaid programs, two problems 
result. First, some of these States do not maintain rosters of all providers 
who participate in their Medicaid managed care plans.  Without such a 
roster, a State Medicaid agency would have trouble determining whether 
a provider who was terminated for cause by another State was 
participating in its own State Medicaid program via one or more managed 
care plans. Second, even if a State Medicaid agency determined that such 
a provider was participating in one or more of its Medicaid managed care 
plans, it may have limited authority to terminate that providers 
participation in Medicaid. If a provider is not in a legal relationship with 
(i.e., enrolled in) a State Medicaid programas with the previously 
mentioned 91 providers who were not directly enrolled by State Medicaid 
programsthe State may have limited authority to terminate the 
providers participation in any of the States Medicaid managed care plans.   
Therefore, such a provider could continue to participate in Medicaid and 
treat Medicaid patients, despite having been terminated for cause from  
Medicare or from another States Medicaid or CHIP programs. 
The other 16 States that used Medicaid managed care required all 
participating providersboth those in managed care plans and those 
participating on a fee-for-service basisto enroll with the State agency.24  
 ____________________________________________________________ 
22 The remaining 11 States did  not  use managed care for their Medicaid programs as of  
June 1, 2012. 

23 Memo to the OIG from the CMS Division  of Field Operations/Medicaid Integrity 
 
Group.  The memo provided information on  52 States, including the District of Columbia
  
and Puerto Rico.  June 4, 2012. 

24 Ibid.   
Providers Terminated From One State Medicaid Program Continued Participating in Other States (OEI-06-12-00030)   10 
   
   
Therefore, these State agencies could use the same processes to terminate 
participation in Medicaid both for managed care providers and 
fee-for-service providers.  
The active status of a providers professional license can cause  
misunderstanding for some State Medicaid agency staff 
Some State Medicaid agency staff appeared to misunderstand the 
significance of a providers State-issued professional license in making 
their decisions about whether to terminate a provider under section 6501 
of the ACA.  When asked about providers whom we identified as having 
continued in Medicaid after they were reported as terminated for cause 
from another State program, staff from 11 States noted that 1 or more of 
those providers had active medical licenses in their States.  During 
followup discussions, some of these staff members expressed a belief that 
if a State licensing board permitted a provider to have an active license to  
practice in the State, they should defer to the judgment of the licensing 
board and not terminate the provider from Medicaid.  However, under 
section 6501 of the ACA, termination is not contingent on a providers 
licensure status. Although a State board may continue to grant a license to 
a provider, the State agency is nonetheless required to terminate the 
providers Medicaid participation based on the providers termination for 
cause from Medicare or from another States Medicaid or CHIP program.  
Providers Terminated From One State Medicaid Program Continued Participating in Other States (OEI-06-12-00030)   11 
   
   
CONCLUSION AND RECOMMENDATIONS  
Section 6501 of the ACA added an important program integrity provision 
to help ensure that providers who are found to warrant terminations for 
cause from Medicare, State Medicaid, or CHIP programs do not continue 
treating Medicaid beneficiaries and receiving Medicaid payments in other 
States. However, we found that 12 percent of providers who were 
terminated for cause from State Medicaid programs in 2011 continued 
participating in Medicaid in other States.  About half of these providers 
remained listed as participating in Medicaid as late as January 2014, and 
about one-third received payments for services provided to Medicaid 
beneficiaries after the providers terminations for cause.    
We found that State Medicaid agencies faced challenges in getting 
information about providers terminated by other States.  Further, State 
Medicaid agencies faced challenges terminating providers once they 
learned of the providers termination for cause by other State agencies.   
In March 2014, OIG recommended that CMS require State Medicaid 
agencies to report all terminations for cause (rather than continuing with 
the prior voluntary-reporting approach) and that CMS improve the 
accuracy and completeness of termination records.25 In response to our 
recommendation, CMS implemented procedures intended to improve the 
completeness of the records.  Nevertheless, we reiterate our prior 
recommendation for CMS to require reporting of all terminations for 
cause, as we found that the lack of a comprehensive data source of 
providers terminated for cause creates a challenge for State Medicaid 
agencies. 
To address the remaining issues identified in this report, we recommend 
that CMS: 
Work with States to develop uniform terminology to clearly  
denote terminations for cause 
States efforts to comply with the requirements of section 6501 of the ACA  
can be hampered by the lack of uniform terminology across States for 
denoting a termination for cause.  CMS should work with State Medicaid 
agencies to develop uniform terminology denoting such terminations for 
cause that could be applicable across all States and all sources of data on 
terminated providers.  This would allow States to more easily differentiate 
between reasons that constitute a termination for cause under section 6501 
of the ACAwhere the provider has exhausted all appeal rights, and there 
____________________________________________________________ 
25 OIG,  CMSs Process for Sharing Information About Terminated  Providers Needs  
Improvement, OEI-06-12-00031, March 2014. 
Providers Terminated From One State Medicaid Program Continued Participating in Other States (OEI-06-12-00030)   12 
   
   
is no expectation that the termination is temporaryand terminations for 
other reasons, such as administrative reasons.  
Require that State Medicaid programs enroll all providers 
participating in Medicaid managed care 
The lack of a legal relationship with the State Medicaid program exempts 
a large number of providers who participate through managed care in the 
25 States that do not directly enroll these providers.  Requiring State 
Medicaid programs to enroll Medicaid managed care providers would 
ensure that State agencies can identify all providers who deliver care to 
Medicaid beneficiaries. Moreover, enrollment would give State agencies 
a mechanism for terminating a providers participation in Medicaid when 
the provider was previously terminated for cause from another program  
for reasons of fraud, integrity, or quality.   
Furnish guidance to State Medicaid agencies that termination is  
not contingent on the providers active licensure status 
Some State Medicaid agencies need clarification regarding providers who 
were terminated for cause from another program yet continue to have an 
active license to practice in their States.  CMS should provide guidance 
regarding how State agencies should handle these situations.  The 
guidance should clarify that the termination of a providers participation 
from Medicaid, when required under section 6501 of the ACA, is not 
contingent on the providers licensure status, but instead required as a 
result of the prior termination for cause from Medicare or from other State 
Medicaid or CHIP programs.   
Providers Terminated From One State Medicaid Program Continued Participating in Other States (OEI-06-12-00030)   13 
   
   
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
CMS concurred with our recommendations and stated that it is committed 
to improving program integrity efforts in the Medicaid program.  CMS 
also stated that it has taken a number of steps to improve States ability to 
address the concerns identified in this report.   
Our first recommendation reiterated a prior recommendation that CMS 
require reporting for all terminations for cause, as we found that the lack 
of a comprehensive data source of providers terminated for cause creates a 
challenge for State Medicaid agencies.  Although CMS described steps it 
had taken to improve the process of sharing information regarding 
terminated providers, it did not indicate that it planned to require State 
reporting of terminations.  Unless CMS requires such reporting, we 
believe that a centralized data source will not be comprehensive.  
In response to our second recommendationthat CMS work with States 
to develop uniform terminology to clearly denote terminations for cause 
CMS stated that it now reviews Medicaid termination letters prior to 
entering the information into the Termination Notification database.  If  
CMS finds that the State has terminated the provider for cause, that 
information is entered into the database.  
In response to our third recommendationthat CMS require that State 
Medicaid programs enroll all providers participating in Medicaid managed 
careCMS described the Notice of Proposed Rulemaking published in 
June 2015 which, if finalized, will require State Medicaid programs to 
enroll these providers. 
In response to our fourth recommendationthat CMS furnish guidance to 
State Medicaid agencies that termination is not contingent upon the 
providers active licensure statusCMS stated that it will work with 
States and educate them  on its policies for terminating providers who have 
been terminated for cause, yet continue to have an active license to 
practice in their respective State.  
We support CMSs efforts to improve program integrity in the Medicaid 
program.  For the full text of CMSs response, see Appendix H. 
Providers Terminated From One State Medicaid Program Continued Participating in Other States (OEI-06-12-00030)   14 
   
   
APPENDIX A: DETAILED METHODOLOGY 
Data Collection and Analysis 
State Medicaid Programs Data on Individual Providers. We obtained 
from each State Medicaid agency its data on all individual providers who  
were participating in the program as of January 1, 2012, on a 
fee-for-service basis and/or as part of a Medicaid managed care plan.  We  
requested the following information: 
   Provider name      Tax identification number  
   Medicaid provider     Legacy provider identification 
identification number  numbers  
   Provider type     State license or certification numbers  
   Provider specialty     Date of birth 
   NPI     Practice address(es) 
   SSN     Billing address(es)  
We followed up with State agencies when we noticed anomalies or 
inconsistencies in the submitted data.  As a result, some agencies provided  
explanations to help ensure that we interpreted their data appropriately and 
some agencies resubmitted data in response to our inquiries.  Some  
agencies also had to request additional data from their Medicaid managed 
care plans.  
State Medicaid Programs Data on Terminated Providers.  From each of 
the State Medicaid agencies, we requested data on individual providers 
who were terminated for cause from their programs during 2011.  These 
data included the same variables contained in the data on individual 
participating providers, with the addition of the Medicaid termination date 
and reason for termination.   
Combined, 56 States submitted data for a total of 2,684 unique providers  
terminated for cause during 2011.26  We followed up with State agencies 
when we noticed anomalies or inconsistencies in the submitted data on 
terminated providers, and we removed from the analysis 145 providers  
records that were missing critical identifying information.  The report 
findings are based on our review of 2,539 unique individual providers who 
were terminated for cause from  46 State Medicaid programs during 
2011.27     
 ____________________________________________________________ 
26 Among the 56 States, 10 reported that  no  Medicaid providers were terminated for  
cause in  2011.  These States were Alabama, Alaska, American Samoa, Delaware, Guam, 
Idaho, Northern Mariana Islands, South Carolina, South Dakota, and the Virgin  Islands.  
27 Twenty-nine providers were reported as terminated by more than  one entity or  by more 
than one State.   
Providers Terminated From One State Medicaid Program Continued Participating in Other States (OEI-06-12-00030)   15 
   
   
We used CMSs National Plan and Provider Enumeration System  
(NPPES) and the Medicare Exclusion Database (MED) as tools to 
supplement information submitted by the States.  Using these data sources 
allowed us to confirm providers identification information in cases where 
State program data did not include an NPI or SSN.  For example, if a State 
submitted a physicians SSN but did not include the physicians NPI, we 
compared the physicians SSN to NPPES and MED to determine and 
verify the physicians NPI, when possible. 
Comparing Terminated Provider Data to Participating Provider Data.    
To identify any providers who continued participating in Medicaid after 
their terminations for cause, we compared the submitted rosters of  
Medicaid providers terminated for cause during 2011 to the submitted 
rosters of providers participating in each other States Medicaid program  
as of January 1, 2012. We determined the number of these providers and 
calculated their percentage among all providers terminated for cause from  
Medicaid during 2011. We also followed up with State Medicaid agencies 
an additional 2 years laterin January 2014to determine whether and 
when each providers participation from Medicaid ended, and the amount, 
if any, that Medicaid paid these providers for services performed after 
their respective termination dates. We calculated the frequency and 
percentage of terminated providers who were still participating in any 
State Medicaid program as of January 2014.   
State Medicaid Payments Data. For each provider who continued 
participating in Medicaid after being terminated for cause, we obtained 
Medicaid payment data from the associated State Medicaid agency.  
Agencies reported data that reflected amounts paid to terminated providers 
for services performed after the termination date through January 2014.  
Using Medicaid payment data submitted by the States, we determined 
which providers terminated for cause were paid for services performed 
after their 2011 terminations, and we calculated the amounts paid. 
Data on Implementation Challenges. To gather information about 
challenges that State Medicaid agencies encountered in implementing the 
ACA requirement, we used three primary sources:  the State Medicaid 
agency staff, with whom we discussed our data requests and followed up 
regarding specific providers; agency responses in the data submitted to 
OIG; and the responses to questionnaires sent to State Medicaid agencies.  
These efforts allowed us to gain an understanding of challenges faced by  
State agencies.  In responses to our questionnaire, which we received from  
April to July 2013, State Medicaid agencies reported the data sources that 
they used to learn about providers terminated for cause from other 
programs.  
Providers Terminated From One State Medicaid Program Continued Participating in Other States (OEI-06-12-00030)   16 
   
   
APPENDIX B:  PROVIDERS REPORTED BY STATE MEDICAID 
AGENCIES AS TERMINATED FOR CAUSE  
Table B-1:  Number of Providers Reported as Terminated For 
Cause in 2011 from State Medicaid Programs by State 
State   Number of Providers* 
New York   609 
New Mexico  431 
Oregon   256 
Tennessee   197 
Ohio   138 
Illinois   116 
Pennsylvania  99 
Arkansas  79 
Georgia  64 
Texas   56 
Kentucky  48 
Florida   47 
Louisiana  42 
New Jersey   41 
Massachusetts   37 
California  37 
Washington  25 
Maryland   24 
Oklahoma   19 
Nebraska   18 
Iowa   16 
Arizona  15 
Utah   15 
Michigan  14 
Wisconsin  14 
Wyoming  12 
Minnesota  10 
Missouri  10 
North Carolina   9 
North Dakota   9 
Source:  OIG analysis of Medicaid  termination data (2011) submitted by State Medicaid agencies. 
*Some providers were reported  terminated by more than one State.  
continued on next page 
 
   
Providers Terminated From One State Medicaid Program Continued Participating in Other States (OEI-06-12-00030)   17 
   
   
APPENDIX B 
Table B-1:  Number of Providers Reported as Terminated For 
Cause in 2011 from State Medicaid Programs by State 
(Continued) 
State   Number of Providers * 
New Hampshire   8 
West Virginia   8 
Colorado   7 
Kansas  6 
Mississippi   6 
Nevada   6 
Hawaii  4 
Rhode Island   4 
Maine  3 
Virginia  3 
Connecticut  2 
Indiana  2 
Puerto Rico   2 
District of Columbia  1 
Montana   1 
Vermont   1 
Alabama  0 
Alaska   0 
American Samoa   0 
Delaware   0 
Guam   0 
Idaho   0 
Northern Mariana Islands  0 
South Carolina   0 
South Dakota   0 
Virgin Islands  0 
Total   2,571 
     Total unique providers terminated     2,539  
Source:  OIG analysis of Medicaid  termination data (2011) submitted by State Medicaid agencies. 
*Some providers were reported  terminated by more than one State Medicaid program. 
 
Providers Terminated From One State Medicaid Program Continued Participating in Other States (OEI-06-12-00030)   18 
   
   
APPENDIX B 
Table B-2:  Number and Percentage of Providers Reported as 
Terminated For Cause in 2011 from State Medicaid Programs, 
by Provider Type 
Number of   Percentage 
Provider Type  
Providers  (n = 2,539)* 
Physician**  819  32%  
Personal Care Attendant   463  18%  
Mental Health Provider (e.g., Psychologist, Counselor, 
422  17%  
Social Worker, Behavioral Health Worker)  
Nurse  200  8%  
Dentist  143  6%  
Nonphysician Practitioner (e.g., Nurse Practitioner,  
Physician Assistant, Certified Registered Nurse Anesthetist,  96  4%  
Certified Nurse Midwife)  
Therapist (e.g., Physical, Occupational, Speech and 
51  2%  
Language, Respiratory)  
Business Owner    50  2%  
Chiropractor   48  2%  
Podiatrist  44  2%  
Business Employee  43  2%  
Nurses Aide  40  2%  
Pharmacist  40  2%  
Unknown   28  1%  
Business Employee/Manager   17  <1%  
Ophthalmologist  9  <1% 
Massage Therapist   8  <1%  
Hearing Service Provider (e.g., Audiologist)  7  <1% 
Acupuncturist  6  <1%  
Medicaid Beneficiary (Who Billed for Care That He/She  
3  <1% 
Provided Family  Members)  
Eye and Vision Service Provider (e.g., Optometrist)   2  <1% 
     Total   2,539   100%  
Source:  OIG analysis of Medicaid  termination data (2011) submitted by State Medicaid agencies.  
*Percentages do not sum to 100% due to rounding. 
 
Providers Terminated From One State Medicaid Program Continued Participating in Other States (OEI-06-12-00030)   19 
   
   
APPENDIX C:  PROVIDERS REPORTED BY STATE MEDICAID 
AGENCIES AS TERMINATED FOR CAUSE AND STILL  
PARTICIPATING IN OTHER STATES 
Table C-1:  Number of Providers Reported as Terminated for 
Cause in 2011 and Participating in Medicaid as of          
January 1, 2012, by State  
Number of Participating Providers 
State 
Terminated by Other States* 
New Mexico  33 
Massachusetts   30 
South Carolina   26 
Texas   26 
Washington  21 
California  20 
Alabama  12 
Kentucky  12 
Arizona  11 
Florida   10 
Ohio   10 
Virginia  10 
Colorado   9 
Indiana  9 
Mississippi   9 
New York   9 
Georgia  8 
Idaho   8 
Nebraska   8 
New Hampshire   8 
Tennessee   8 
West Virginia   8 
Illinois   7 
Maine  7 
Maryland   7 
Delaware   6 
Kansas  6 
Minnesota  6 
Missouri  6 
North Carolina   6 
Source:  OIG analysis of Medicaid  termination data (2011) and participating provider data (January 1, 2012) 

submitted by State Medicaid agencies. 

*Some providers were reported as  participating by more than one State. 
 
continued on next page 
Providers Terminated From One State Medicaid Program Continued Participating in Other States (OEI-06-12-00030)   20 
   
   
APPENDIX C 
Table C-1:  Number of Providers Reported as Terminated for 
Cause in 2011 and Participating in Medicaid as of          
January 1, 2012, by State (Continued) 
Number of Participating Providers 
State 
Terminated by Other States* 
Oklahoma   6 
Oregon   6 
Utah   6 
Arkansas  5 
Iowa   5 
Michigan  5 
Pennsylvania  5 
Wisconsin  5 
Louisiana  4 
Wyoming  4 
Hawaii  3 
Montana   3 
Nevada   3 
Rhode Island   3 
Connecticut  2 
District of Columbia  1 
New Jersey   1 
Alaska   0 
American Samoa   0 
Guam   0 
North Dakota   0 
Northern Mariana Islands  0 
Puerto Rico   0 
South Dakota   0 
Vermont   0 
Virgin Islands  0 
Total   295 
Source:  OIG analysis of Medicaid  termination data (2011) and participating provider data (January 1, 2012) 

submitted by State Medicaid agencies. 

*Some providers were reported as  participating in more than one State Medicaid program. 
 
 
   
Providers Terminated From One State Medicaid Program Continued Participating in Other States (OEI-06-12-00030)   21 
   
   
APPENDIX C 
Table C-2:  Number and Percentage of Providers Reported as 
Terminated for Cause in 2011 and Participating in Medicaid in 
Other States as of January 1, 2012, by Provider Type  
Number of   Percentage  
Provider Type  
Providers  (n = 295)* 
Physician**  222  75%  
Mental Health Provider (e.g., Psychologist, Counselor, 
33  11%  
Social Worker, Behavioral Health Worker)  
Dentist  16  5%  
Nonphysician Practitioner (e.g., Nurse Practitioner,  
Physician Assistant, Certified Registered Nurse Anesthetist,  10  3%  
Certified Nurse Midwife)  
Ophthalmologist  3  1%  
Podiatrist  3  1%  
Therapist (e.g., Physical, Occupational, Speech and 
3  1%  
Language, Respiratory)  
Hearing Service Provider (e.g., Audiologist)  2  <1% 
Acupuncturist  1  <1%  
Nurses Aide  1  <1% 
Personal Care Attendant   1  <1% 
     Total   295  100%  
Source:  OIG analysis of Medicaid  termination data (2011) and participating provider data (January 1, 2012), 

submitted by State Medicaid agencies.  

*Percentages do not sum to 100% due to rounding. 

**States were more likely to submit an  NPI or SSN for the  physicians in our sample than for other health care 
 
providers.  Because our provider comparison was heavily dependent on the  matching of NPIs and SSNs, this may 
 
account for the  greater  number of physicians identified. 

 
   
Providers Terminated From One State Medicaid Program Continued Participating in Other States (OEI-06-12-00030)   22 
   
   
APPENDIX D:  PAYMENTS TO PROVIDERS REPORTED AS 
TERMINATED FOR CAUSE 
Table D-1:  State Medicaid Program Payments for Services 
Delivered by Terminated Providers After Dates of Terminations 
For Cause, by State  
Number of  
State  Total Payments 
Providers Paid* 
California  7  $1,691,573  
Mississippi   4  $1,204,999  
Wyoming  4  $919,087  
Idaho   6  $821,219  
Kansas  2  $807,828  
Arkansas  2  $397,887  
Connecticut  2  $316,847  
Florida   4  $292,644  
Kentucky  9  $193,680  
Maine  4  $175,207  
Tennessee  3  $145,200  
Oklahoma   2  $119,484  
Utah  4  $62,536  
Wisconsin  5  $61,272  
Illinois  6  $43,852  
Ohio   1  $40,906  
South Carolina   16  $32,849  
West Virginia   3  $24,186  
Missouri  3  $18,782  
Hawaii  2  $13,043  
Georgia  2  $8,274  
New Jersey   1  $7,309  
Pennsylvania  2  $5,402  
Iowa   1  $2,021  
Nebraska  1  $1,621  
Virginia  2  $1,304  
Alabama  1  $695  
Delaware   1  $381  
North Carolina   1  $301  
Minnesota  1  $82 
Massachusetts  1  $45 
Michigan  1  $39 
New York   1  $11 
    Total Unique  Providers   94  $7,410,568  
Source:  OIG analysis of Medicaid  termination data (2011), participating provider data (January 1, 2012), and 
 
payment data (as of  January 2014)  submitted by State Medicaid agencies. 

*Some providers were paid by more than one State. 
 
Providers Terminated From One State Medicaid Program Continued Participating in Other States (OEI-06-12-00030)   23 
   
   
  
APPENDIX D 
Table D-2:  Number and Percentage of Providers Reported as 
Terminated for Cause in 2011 and Paid for Services Delivered 
after Termination Date, by Provider Type 
Number of   Percent 
Provider Type  
Providers  (n = 94)* 
Physician**  78  83%  
Dentist  6  6%  
Nonphysician Practitioner (e.g., Nurse Practitioner, Physician 
Assistant, Certified Registered Nurse Anesthetist, Certified  4  4%  
Nurse Midwife)  
Mental Health Provider (e.g., Psychologist, Counselor, Social 
4  4%  
Worker, Behavioral Health Worker)  
Ophthalmologist  1  1%  
Therapist (e.g., Physical, Occupational, Speech and Language, 
1  1% 
Respiratory)  
     Total   94  100%  
Source:  OIG analysis of Medicaid  termination data (2011), participating provider data (January 1, 2012), and 
 
payment data (as of  January 2014)  submitted by State Medicaid agencies. 

*Percentages do not sum to 100% due to rounding. 

**States were more likely to submit an  NPI or SSN for the  physicians in our sample than for other health care 
 
providers.  Because our provider comparison was heavily dependent on the  matching of NPIs and SSNs, this may 
 
account for the  greater  number of physicians identified.
 
 
   
Providers Terminated From One State Medicaid Program Continued Participating in Other States (OEI-06-12-00030)   24 
   
   
APPENDIX E:  DATA SOURCES USED BY STATE MEDICAID 
AGENCIES 
Table E-1:  Data Sources State Medicaid Agencies Reported 
Using to Learn About Terminated Providers 
Data System  Information Provided  Entities with Access  
CMS Termination  Providers terminated for cause  State Medicaid agencies and CMS 
Notification Database  from the Medicare, Medicaid, and  staff 
(formerly MCSIS)1   CHIP programs  
Fraud Investigation  Fraudulent activity and payment  State Medicaid agencies and CMS 
Database2   suspensions related to Medicare  staff; Medicare contractors; law  
and Medicaid providers  enforcement agencies 
General Services  Individuals and entities barred  State Medicaid agencies and CMS 
Agency (GSA)  from receiving Federal contracts,  staff and contractors; general public; 
System for Award  certain subcontracts, and certain  grant officials 
Management3   types of Federal financial and 
nonfinancial assistance and 
benefits 
Medicare Exclusion  All the OIG exclusion data that is  State Medicaid agencies and CMS 
Database4  updated monthlythe data are  staff and contractors; other approved 
used to deny claims submitted  entities  
from excluded providers 
OIG List of Excluded  Information on providers  State Medicaid agencies and CMS 
Individuals and  excluded by OIG from  staff and contractors; general public  
Entities5, 6   participation in a Federal or State 
health care program 
Provider Enrollment,  Medicare final adverse actions  State Medicaid agencies and CMS 
Chain and Ownership  (e.g., revocation of billing  staff and contractors; providers; 
System7  privileges; licensure suspension  suppliers; other authorized users  
or revocation; exclusion or 
debarment from participation in a 
Federal or State healthcare 
program)  
Sources:    
1  CMS, CPI-B 11-05, ACA Program Integrity ProvisionsGuidance to StatesSection  6501Termination  of  
Provider Participation Under Medicaid if Terminated Under Medicare or Other State Plan, May 31, 2011.    
2  CMS, Fraud Investigation Database:  Overview, January 15, 2013.  Accessed  at http://www.cms.gov/Research-
Statistics-Data-and-Systems/Computer-Data-and-Systems/FID-2/Overview.html on May 7, 2014. 
3  GSA,  System for Award Management User Guide.   Accessed at  
https://www.sam.gov/sam/transcript/System_for_Award_Management_v2.8.pdf on May 7, 2014. 
4  CMS, Medicare Exclusion Database (MED) FAQs. Accessed at http://www.eushelpdesk.com/IACS/med.html   
on May 7, 2014.  
5 CMS, CPI-B 11-05,  ACA Program Integrity ProvisionsGuidance to StatesSection  6501Termination  of  
Provider Participation Under Medicaid if Terminated Under Medicare or Other State Plan, May 31, 2011.  
6  OIG,  List of  Excluded Individuals and Entities.  Accessed at  www.oig.hhs.gov on  May 7, 2014.  
7 CMS, The Basics of Internet-based  Provider  Enrollment, Chain and Ownership System (PECOS) for Physicians  
and Non-Physician Practitioners, ICN 903764, May 2013.  Accessed at  www.cms.gov on May 7, 2014.  National  
Provider Call:  Streamlined Access to  PECOS, EHR, and  NPPES, November 15, 2013.  Accessed at  
http://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/NPC-PECOS-11-15-13-Transcript.pdf on 
July 21, 2014.  
   
Providers Terminated From One State Medicaid Program Continued Participating in Other States (OEI-06-12-00030)   25 
   
   
APPENDIX F:  REASONS FOR TERMINATIONS FOR CAUSE  
State Medicaid agencies provided termination reasons, which we then 
collapsed into categories based upon additional descriptive information 
included in the State agencys data submission. 
 
Table F-1:  Termination Reasons Submitted by State Medicaid 
Agencies  
Number of   Percentage 
Termination Reason  
Providers*  (n = 2,570)** 
Reason listed simply as termination  1,021   40%  
State regulation cited   611  24%  
License suspension, revocation, surrender, or other State 
329  13%  
action 
Federal exclusion   129  5%  
Criminal charges, indictment, or conviction   100  4%  
Suspension  80  3%  
Sanction  69  3%  
State exclusion  60  2%  
Reasons related to fraud, quality,  or integrity    58  2%  
Termination by CMS   35  1%  
Policy violation  20  1%  
Other  16  1%  
Credential related   15  1%  
OIG and State exclusion   12  <1% 
Unknown  9   <1% 
Failure to disclose required information or criminal charges  7  <1% 
Termination by  Medicaid managed care plan due to 
5  <1%  
improper billing concerns 
OIG or CMS sanction   2  <1% 
     Total   2,576   100%  
Source:  OIG analysis of Medicaid  termination data (2011) submitted by State Medicaid agencies. 

*Some providers were reported as  terminated by more than one State or by both the State Medicaid agency and 

Medicaid managed  care organizations within the same State. 

**Percentages do not sum to 100% due to rounding. 

 
   
Providers Terminated From One State Medicaid Program Continued Participating in Other States (OEI-06-12-00030)   26 
   
   
APPENDIX G:  STATE MEDICAID AGENCY ENROLLMENT OF 
MEDICAID MANAGED CARE PROVIDERS 
 
Table G-1:  State Agencies That Enroll Medicaid Managed Care  
Providers In the Same Manner as Fee-For Service Medicaid 
Providers, June 2012 
Did Not 
Use 
State  Yes  No  Medicaid 
Managed 
Care  
Alabama      
Alaska        
Arizona     
Arkansas       
California     
Colorado        
Connecticut     
Delaware        
District of Columbia       
Florida        
Georgia       
Hawaii       
Idaho        
Illinois        
Indiana       
Iowa        
Kansas     
Kentucky       
Louisiana     
Maine       
Maryland        
Massachusetts        
Michigan     
Minnesota       
Mississippi        
Missouri       
Montana        
Nebraska        
Nevada        
 
Source:   Memo to  OIG from the CMS  Division of Field Operations/Medicaid Integrity Group, June 4, 2012  
continued on next page 
Providers Terminated From One State Medicaid Program Continued Participating in Other States (OEI-06-12-00030)   27 
   
   
APPENDIX G 
   
Table G-1:  State Agencies That Enroll Medicaid Managed 
Care Providers the Same as Fee-For Service Medicaid 
Providers, June 2012 (continued)  
Did Not 
Use 
State   Yes   No   Medicaid 
Managed 
Care 
New Hampshire        
New Jersey        
New Mexico       
New York        
North Carolina        
North Dakota        
Ohio        
Oklahoma        
Oregon        
Pennsylvania       
Puerto Rico        
Rhode Island        
South Carolina        
South Dakota        
Tennessee        
Texas        
Utah        
Vermont        
Virginia       
Washington       
West Virginia        
Wisconsin       
Wyoming       
     Total   16  25  11 
 
Source:   Memo to  OIG from the CMS  Division of Field Operations/Medicaid Integrity Group, June 4, 2012  
Providers Terminated From One State Medicaid Program Continued Participating in Other States (OEI-06-12-00030)   28 
  APPENDIX H:  AGENCY COMMENTS 

l-4
~!P-Vlc:~.~ 
DEPARTMENT OF HEALTH & HUMAN SERVICES  Centers for Medicare & Medicaid Services 
200 Independence Avenue SW 
Washington, DC 20201 
DATE:  JUN 19 20t5 
TO: 	 Daniel R. Levinson 

Inspector General 

FROM: 	 Andrew M. Slavitt 

Acting Administrator 

SUBJECT: 	 Office ofInspector General (OIG) Draft Report: "Providers Terminated from One 
State Medicaid Program Continued Participating in Other States" (OEI-06-12
00030) 
The Centers for Medicare and Medicaid Services (CMS) appreciates the opportunity to review 
and comment on the Office oflnspector General's (OIG) draft report. CMS is committed to 
improving program integrity efforts in the Medicaid program. 
While OIG has analyzed data from 2011, CMS has since taken a number ofsteps to enhance 
states' ability to terminate potentially fraudulent providers and address the concerns identified in 
this report. In February 2011, CMS issued regulations under which states must implement 
categorical risk-based screening ofnewly enrolling Medicaid providers and revalidate all current 
Medicaid providers under new requirements established by the Affordable Care Act Providers 
are assigned to categorical screening levels based on factors such as the type ofservice provided 
and history ofprevious adverse actions. 
These regulations also require state Medicaid agencies to deny or terminate the enrollment ofany 
provider that has been terminated for cause under Medicare or another state's Medicaid program 
or CHIP after January 1, 2011. In order to assist states with this requirement, CMS provided 
states with tools to view information on Medicare providers and suppliers in a denied or revoked 
status and to share information about Medicaid providers terminated from Medicaid programs in 
other states. In 2014, this process was further improved through the implementation ofa new 
Medicaid termination system. Under this new process, states submit information to CMS 
regarding provider terminations, including a copy ofthe Medicaid termination letter issued to the 
provider as well as critical data fields, such as the National Provider Identifier. CMS reviews 
submitted termination letters to verify that the termination was for cause and then enters those 
that are for cause into the termination notification database. State Medicaid programs can access 
this repository ofall state-submitted Medicaid provider terminations and Medicare provider 
revocations. This allows states to access current provider termination information and assists 
them in terminating potentially fraudulent Medicaid providers more quickly. 
CMS has also taken steps to make sure Medicaid managed care providers are directly enrolled in 
Medicaid. Since 2011, CMS has periodically published guidance to states that identifies as a best 
practice requiring all managed care network providers to be enrolled in Medicaid in the same 
Providers Terminated From One State Medicaid Program Continued Participating in Other States (OEI-06-12-00030)  29   
   
APPENDIX H: AGENCY COMMENTS (continued) 
   
Providers Terminated From One State Medicaid Program Continued Participating in Other States (OEI-06-12-00030)   30 

   
   
ACKNOWLEDGMENTS 
This report was prepared under the direction of Kevin Golladay, Regional 
Inspector General for Evaluation and Inspections in the Dallas regional 
office, Blaine Collins, Deputy Regional Inspector General, and  
Ruth Ann Dorrill, Deputy Regional Inspector General.  
Deborah Cosimo served as the team leader for this study.  Other Office of 
Evaluation and Inspections staff from the Dallas regional office who 
conducted the study include Nathan Dong and Malinda Hicks.  Office of 
Evaluation and Inspections staff who provided support include  
Janna Sayer from the Atlanta regional office and Vincent Greiber from the 
New York regional office.  Central office staff who provided support 
include Clarence Arnold, Eddie Baker, Kevin Manley, and  
Christine Moritz. Office of Management and Policy staff who contributed 
to this report include Jessica Swanstrom.   
Providers Terminated From One State Medicaid Program Continued Participating in Other States (OEI-06-12-00030)   31 
   
Office of Inspector General
http://oig.hhs.gov  
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as  
amended, is  to protect the integrity of the Department of  Health and Human Services  
(HHS)  programs, as well as the health and welfare of beneficiaries  served by those 
programs.  This statutory mission  is  carried  out through  a nationwide network  of  audits, 
investigations, and inspections conducted by the  following operating components: 
Office of Audit Services 
The Office  of  Audit Services  (OAS) provides auditing services  for HHS, either by  conducting  
audits  with its own audit resources or by  overseeing  audit work done by others.  Audits  
examine the performance of HHS programs and/or its grantees and contractors in carrying  
out their respective responsibilities and are intended  to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and  
mismanagement and promote economy and efficiency  throughout  HHS. 
Office of Evaluation and Inspections 
The Office  of  Evaluation and Inspections (OEI)  conducts national evaluations to  provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud,  waste, or abuse  and promoting  
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations  
of  fraud and misconduct  related to HHS programs, operations, and beneficiaries.  With 
investigators working in all 50 States and the District of Columbia, OI  utilizes its resources 
by actively  coordinating with the Department  of Justice  and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to  criminal 
convictions, administrative sanctions,  and/or  civil monetary  penalties.  
Office of Counsel to the Inspector General 
The Office of Counsel to the  Inspector  General (OCIG) provides general legal services to 
OIG, rendering  advice and opinions on HHS programs  and operations and providing all 
legal support for OIGs  internal operations.  OCIG represents  OIG in all civil and 
administrative fraud and abuse cases involving HHS programs,  including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In  connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program  guidance, publishes fraud alerts, and provides other  
guidance  to  the health care industry concerning the anti-kickback statute and other  OIG  
enforcement authorities.