U.S. Department of Health and Human Services 
Office of Inspector General 
 
 
States Could Do 
More To Prevent 
Terminated 
Providers From 
Serving Medicaid 
Beneficiaries
Christi A. Grimm 
OEI-03-19-00070 
Principal Deputy 
March 2020 
Inspector General 
 
oig.hhs.gov  Report in Brief  U.S. Department of Health and Human Services 
March 2020 
Office  of Inspector General 
OEI-03-19-00070 
 
 
States Could Do More To Prevent Terminated 
Why OIG Did This Review 
Providers From Serving Medicaid Beneficiaries   The Cures Act includes specific 
program integrity requirements to 
To avoid paying providers whose actions  ensure that States do not spend 
pose a threat to Medicaid and its  Key Takeaway  Medicaid funds on items and 
beneficiaries, States must terminate providers  Terminated providers are  services associated with 
from their Medicaid programs for certain  still serving Medicaid  terminated providers.  In addition, 
reasons such as fraudulent activity and  beneficiaries despite the  as of July 1, 2018, the Cures Act 
criminal convictions.  Moreover, States must  requirements of the  requires State contracts with MCOs 
terminate a provider if that provider has been  21st Century Cures Act that  to include a provision that 
terminated for cause in Medicare or in  were designed to  providers who were terminated 
another States Medicaid program or  strengthen Medicaid  from Medicare, Medicaid, or CHIP 
Childrens Health Insurance Program (CHIP).   program integrity.    cannot participate in their 
This requirement helps ensure that providers  Medicaid managed care networks.  
whose actions threaten the Medicaid  The Cures Act required OIG to 
program and its beneficiaries in one State do not continue to treat Medicaid  determine the following: 
beneficiaries in other States.  (1) whether providers in CMSs 
termination database are 
What OIG Found  terminated from Medicaid in all 
Nearly 1,000 terminated providersor 11 percent of all terminated providers States, (2) the amount of Medicaid 
were inappropriately enrolled in State Medicaid programs or were associated with   payments associated with 
$50.3 million in Medicaid payments after being terminated.  These providers had  terminated providers, (3) whether 
been terminated for reasons such as criminal convictions, licensure issues, and  State contracts with MCOs 
provider misconduct and thus potentially posed a risk to beneficiaries safety and  included a required provision that 
quality of care.    prohibits providers terminated 
from Medicare, Medicaid, or CHIP 
In addition, only eight States managed care contracts all clearly included the 
from participating in Medicaid 
provisionrequired by the 21st Century Cures Act (Cures Act)that prohibits 
managed care networks, and 
terminated providers from participating in Medicaid managed care networks.  This 
(4) the amount of Medicaid 
vulnerability may allow terminated providers to serve Medicaid beneficiaries and 
payments to MCOs that did not 
reduce States ability to limit these providers participation in Medicaid managed 
have the required provision in their 
care networks.  At the time of our review, the Centers for Medicare & Medicaid 
contracts. 
Services (CMS) did not check for this Cures Act-required provision when reviewing 
States contracts with managed care organizations (MCOs).  Overall, States paid at  How OIG Did This Review 
least $62.3 billion in capitation payments to plans under contracts that did not  From CMS, we requested its 
include the required provision.  termination database, which 
contains information on 
Finally, States did not always provide complete and accurate Medicaid data to 
terminated providers reported by 
CMS, which limited the breadth of our analysis of claims, encounter records, and 
States.  We requested rosters of 
payments associated with terminated providers.  Therefore, our findings 
enrolled providers from States.  
understate the payments associated with contracts that did not contain the 
We reviewed State enrollment 
required Cures Act provision and may understate the payments associated with 
rosters dated between January and 
terminated providers.   
May 2019.  We compared 
terminated providers listed in 
    
CMSs February 2019 termination 
   database to the providers in   Report in Brief  U.S. Department of Health and Human Services 
March 2020 
    Office of Inspector General 
OEI-03-19-00070 
 
 
 
What OIG Recommends and How the Agency Responded 
States rosters of enrolled 
To promote States compliance with the requirements of the Cures Act, we  Medicaid providers.   
recommend that CMS (1) recover from States the Federal share of inappropriate 
We also identified fee-for-service 
fee-for-service Medicaid payments associated with terminated providers, 
claims and managed care 
(2) implement a method to recover from States the Federal share of inappropriate 
encounter records associated with 
managed care capitation payments associated with terminated providers, 
terminated providers on or after 
(3) follow up with States to remove terminated providers that OIG identified as 
July 1, 2018.  We determined 
inappropriately enrolled in Medicaid, (4) confirm that States do not continue to 
whether these providers were 
have terminated providers enrolled in their Medicaid programs, (5) safeguard 
enrolled in Medicaid.  Finally, we 
Medicaid from inappropriate payments associated with terminated providers, and 
examined State contracts with 
(6) review States contracts with MCOs to ensure that they clearly and specifically 
MCOs to determine whether States 
include the required provision that prohibits terminated providers from 
included in their contracts with 
participating in Medicaid managed care networks.  CMS concurred with all six of 
MCOs a provision that terminated 
our recommendations.
providers are terminated from all 
Medicaid managed care networks. 
Full report can be found at oig.hhs.gov/oei/reports/oei-03-19-00070.asp   
TABLE OF CONTENTS 
BACKGROUND  1 
Methodology  5 
   
FINDINGS   
Eleven percent of terminated providers were still able to serve Medicaid beneficiaries  7 
Only eight States had managed care contracts that all clearly included the required  12 
provision that prohibits terminated providers from participating in Medicaid managed care 
networks  
States incomplete reporting of required Medicaid data prevented a comprehensive  14 
assessment of the financial impact of terminated providers on Medicaid 
   
CONCLUSION AND RECOMMENDATIONS   
Recover from States the Federal share of inappropriate fee-for-service Medicaid payments  17 
associated with terminated providers 
Implement a method to recover from States the Federal share of inappropriate managed  17 
care capitation payments associated with terminated providers 
Follow up with States to remove terminated providers that OIG identified as inappropriately  17 
enrolled in Medicaid 
Confirm that States do not continue to have terminated providers enrolled in their Medicaid  18 
programs 
Safeguard Medicaid from inappropriate payments associated with terminated providers   18 
Review States contracts with managed care organizations to ensure that they specifically  18 
include the required provision that prohibits terminated providers from participating in 
Medicaid managed care networks 
   
AGENCY COMMENTS AND OIG RESPONSE  19 
 
APPENDICES   
A: Detailed Methodology  20 
B: Number of Terminated Providers Enrolled in Each State Medicaid Program  27 
C: Medicaid Payments Associated With Terminated Providers, by State  29 
D: Number of Claims and Encounter Records Associated With Terminated Providers,  31 
by Service Type and Provider Type 
   
E: Medicaid Payments for Managed Care Contracts That Did Not Clearly Include the  32 
Required Provision That Prohibits Terminated Providers From Participating in Medicaid 
Managed Care Networks 
F. Agency Comments  34 
   
ACKNOWLEDGMENTS  37 
   
BACKGROUND 
Objectives 
1.  To determine the extent to which providers terminated for 
cause continued to be enrolled in State Medicaid programs 
and the amount that Medicaid paid for items or services 
associated with providers terminated for cause. 
2.  To determine the extent to which States included provisions 
in their contracts with managed care organizations requiring 
that terminated providers be prohibited from participating in 
Medicaid managed care networks, and the amount that 
Medicaid paid to managed care organizations with contracts 
that did not include the provision. 
 
The Medicaid program provides health coverage to approximately 
74 million people at an annual cost of nearly $600 billion.  Given the 
number of beneficiaries and the amount of expenditures, Medicaid 
program integrity is critical to preventing inappropriate payments and 
protecting beneficiaries.  Accordingly, to avoid paying providers whose 
actions pose a threat to Medicaid and its beneficiaries, States must 
terminate providers that engage in behavior related to fraud, integrity, or 
quality issues.  These providers are terminated from Medicaid for 
cause.1, 2  For example, States must terminate a provider for cause if the 
provider has a recent criminal conviction related to Medicaid.3  We use 
the term providers to mean Medicaid providers that are individuals, 
institutions, or organizations, such as doctors, hospitals, and pharmacies.   
Federal rules require States to terminate a provider if that provider has 
been terminated for cause in Medicare, or another States Medicaid 
 
 
1 42 CFR  455.101,  455.416.  CMS, Medicaid Provider Enrollment Compendium, 
 1.10.1(a)(4) and 1.10.2.  Accessed at https://www.medicaid.gov/affordable-care-
act/downloads/program-integrity/mpec-7242018.pdf on August 3, 2018. 
2 For the purposes of this report, we are referring to terminations for cause when we use 
terminations or terminated providers. 
3 42 CFR  455.416; See also CMS, Medicaid Provider Enrollment Compendium 
 1.10.2(b)(3)(ii).  Accessed at https://www.medicaid.gov/affordable-care-
act/downloads/program-integrity/mpec-7242018.pdf on August 3, 2018.  The criminal 
conviction must be related to the providers involvement with Medicare, Medicaid, or CHIP 
within the preceding 10 years. 
 
States Could Do More To Prevent Terminated Providers From Serving Medicaid Beneficiaries  1 
OEI-03-19-00070   
program or States Childrens Health Insurance Program (CHIP).4, 5  This 
requirement helps ensure that providers whose actions threaten the 
Medicaid program and its beneficiaries in one State do not continue to 
treat Medicaid beneficiaries and receive Medicaid payments in other 
States.   
Despite this requirement, a 2015 Office of Inspector General (OIG) report 
found that 12 percent of Medicaid providers terminated by a State in 
2011 were still enrolled in other States in 2012.  The report also found 
that, as of January 2014, States paid $7.4 million to providers that had 
been terminated from Medicaid in 2011.6   
Since OIG issued the 2015 report, Congress passed the 21st Century Cures 
Act (Cures Act) in December 2016, which aimed to strengthen Medicaid 
program integrity by requiring CMS and States to take appropriate action 
to safeguard Medicaid from terminated providers.  
The Cures Act also requires OIG to complete a study and submit a report 
to Congress on the implementation of specific provisions of the Cures Act 
related to terminated providers.  The Cures Act requires OIG to 
(1) determine the extent to which providers included in CMSs termination 
database are terminated from participation in all State Medicaid 
programs; (2) determine the amount of Medicaid payments associated 
with terminated providers; (3) assess the extent to which State contracts 
with managed care organizations (MCOs) included a required provision 
that prohibits providers that were terminated from Medicare, Medicaid, or 
CHIP from participating in Medicaid managed care networks; and 
(4) determine the amount of Medicaid payments to MCOs that did not 
have the required provision in their contracts. 
 
The Medicaid  States administer and finance Medicaid using State and Federal funds.  
Each State has the flexibility to administer its Medicaid program within 
Program 
broad Federal guidelines, resulting in various combinations of health care 
delivery and payment systems in each State.  Generally, States offer 
Medicaid services through a fee-for-service (FFS) model, by contracting 
with MCOs, or through a combination of both.   
The FFS and managed care models differ in how they pay providers for 
items and services.  Under the FFS model, providers submit claims to the 
 
 
4 P.L. No. 111-148  6501.  42 CFR  455.416.   
5 CMS, Medicaid Provider Enrollment Compendium  1.10.2(b)(3)(iii).  Accessed at 
https://www.medicaid.gov/affordable-care-act/downloads/program-integrity/mpec-
7242018.pdf on August 3, 2018. 
6 OIG, Providers Terminated from One State Medicaid Program Continued Participating in 
Other States, OEI-06-12-00030, August 2015. 
States Could Do More To Prevent Terminated Providers From Serving Medicaid Beneficiaries  2 
OEI-03-19-00070   
State for Medicaid items or services and the State directly reimburses 
them.  Under managed care, a State pays an MCO a per-member, 
per-month feeknown as a capitation paymentfor each person 
enrolled with the MCO.  The MCO then pays network providers for all 
Medicaid services included in the MCOs contract with the State.  The 
MCO submits encounter records to the State for the items and services 
provided to Medicaid beneficiaries. 
Medicaid Enrollment 
Provider enrollment is an important program integrity tool that assists 
States in preventing Medicaid fraud, reducing inappropriate payments, 
and protecting beneficiaries.  Providers in FFS and managed care 
networks must enroll in Medicaid.7  Each State is required to screen 
providers enrollment applications to ensure they meet all requirements 
for participation in the Medicaid program.  If a State approves a providers 
enrollment application, the provider is considered active and may serve 
Medicaid beneficiaries.8   
Transformed Medicaid Statistical Information System 
The Transformed Medicaid Statistical Information System (T-MSIS) 
contains Medicaid claims and encounter data as well as other important 
program information such as capitation payments and data on beneficiary 
eligibility and provider enrollment.  CMS established T-MSIS to create a 
national Medicaid database that modernized and enhanced the previous 
reporting system.     
  
Medicaid  The Cures Act includes specific program integrity requirements to ensure 
that States do not spend Medicaid funds on terminated providers.  
Requirements 
Beginning July 1, 2018, the Cures Act prohibits States from making 
Regarding 
Medicaid payments to terminated providers.  Specifically, Federal 
Terminated  payments to States cannot be made for Medicaid items or services 
associated with a terminated provider more than 60 days after CMS 
Providers  
publishes that providers termination.9  In addition, as of July 1, 2018, the 
Cures Act requires State contracts with MCOs to include a provision that 
providers terminated from Medicare, Medicaid, or CHIP cannot participate 
in Medicaid managed care networks.  
 
 
 
 
7 P.L. No 114-255  5005(b)(1),(2). 
8 We use the term enrolled to mean that a provider has an active enrollment status. 
9 P.L. No. 114-255  5005(a)(4)(A)(iii). 
States Could Do More To Prevent Terminated Providers From Serving Medicaid Beneficiaries  3 
OEI-03-19-00070   
Termination Database 
The Cures Act includes requirements for both States and CMS regarding 
the reporting and publication of information on terminated providers.  As 
required by the Cures Act, a State must notify CMS that it has terminated 
a provider within 30 days of the termination.  CMS, in turn, generally must 
publish information on these providers in a termination database 
accessed by all States (Adverse Actions Report).10  CMS maintains the 
termination database within a Web-based interfacethe Data Exchange 
System, or DEXand it is updated in real-time.   
The database contains information on all terminated Medicaid providers 
including, but not limited to, the providers name, National Provider 
Identifier (NPI), Employer Identification Number (EIN), Social Security 
Number (SSN), the reason for termination, and the date CMS published 
the termination, hereafter referred to as the published date.11  The 
termination database also includes providers whose Medicare billing 
privileges have been revoked; these providers must therefore be 
terminated from Medicaid as well.12 
 
Related OIG Work  A 2014 report found that not all States submitted information on 
terminated providers to CMSs Medicaid and Childrens Health Insurance 
Program State Information Sharing System (MCSIS).13, 14  OIG found that 
more than half of the records in MCSIS did not contain NPIs or other 
identifying information.  OIG recommended that CMS require each State 
to report all terminated providers, ensure that this information meet 
CMSs criteria for inclusion, and improve the completeness of records.     
As noted previously, a 2015 OIG report found that 12 percent of Medicaid 
providers terminated by one State in 2011 were still enrolled as providers 
in other States in 2012.  OIG again recommended that States be required 
to report terminated providers and recommended that CMS work with 
 
 
10 P.L. No. 114-255  5005(a)(3).  Section 6401(b)(2) of P.L. No. 111-148 (the Affordable 
Care Act) required CMS to establish a process to make termination information available 
to State Medicaid agencies.  Section 5005(a)(3) of P.L. No. 114-255 (the Cures Act) 
required CMS to include appropriate terminations in the database or similar system 
developed pursuant to the Affordable Care Act provision. 
11 CMS, Medicaid Provider Enrollment Compendium  1.10.4(c), (d).  Accessed at 
https://www.medicaid.gov/affordable-care-act/downloads/program-integrity/mpec-
7242018.pdf on August 3, 2018. 
12 Hereafter when we refer to terminated providers listed in CMSs database, we include 
the providers revoked by Medicare. 
13 OIG, CMSs Process for Sharing Information About Terminated Providers Needs 
Improvement, OEI-06-12-00031, March 2014. 
14 MCSIS was a system in place before the DEX system was established. 
States Could Do More To Prevent Terminated Providers From Serving Medicaid Beneficiaries  4 
OEI-03-19-00070   
States to develop uniform terminology to clearly denote terminations for 
cause. 
CMS concurred with OIGs recommendations in both reports, and 
requirements in the Cures Act helped to address these recommendations. 
 
Methodology  Terminated Providers Enrolled in State Medicaid Programs 
To determine whether any terminated providers were enrolled in State 
Medicaid programs, we collected information from State Medicaid 
agencies and from CMSs termination database.  We collected a roster of 
enrolled Medicaid providers from all 50 States and the District of 
Columbia (States).  To determine the number of terminated providers still 
enrolled in States Medicaid programs, we then compared the providers 
on States enrollment rosters to terminated providers included in CMSs 
termination database.  We received enrollment roster information from 
the States covering time periods between January and May 2019.  CMSs 
termination database was current as of February 2019.       
Payments Associated with Terminated Medicaid Providers 
To identify FFS claims, managed care encounter records, and payments 
associated with terminated providers, we compared provider information 
in CMSs termination database to provider information on Medicaid final 
action claims and encounter records.15  From CMSs T-MSIS data, we 
obtained Medicaid final action claims and encounter records as well as 
the capitation rate paid to MCOs by States.    
We calculated how much Medicaid paid for items or services associated 
with terminated providers in two ways.  For FFS claims associated with 
terminated providers, we aggregated total Medicaid paid amounts.  For 
managed care encounter records associated with terminated providers, 
we aggregated the monthly capitation amounts that States paid for each 
beneficiary associated with these encounter records.  For both FFS and 
managed care payments, we applied the States Federal Medical 
Assistance Percentage (FMAP) to calculate the Federal portion of the 
payments.16 
In conducting this analysis, we also determined whether terminated 
providers associated with Medicaid payments were appropriately enrolled, 
inappropriately enrolled, or not enrolled in Medicaid at the time of our 
enrollment review.  
 
 
15 A final action record is the version of the record in which all adjustments to earlier 
versions of the record have been resolved.   
16 The Federal government uses the FMAP to calculate the share of total Medicaid 
expendituresincluding both FFS and managed carethat it will pay to the States. 
States Could Do More To Prevent Terminated Providers From Serving Medicaid Beneficiaries  5 
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Inclusion of the Required Provision in Managed Care Contracts  
For the States that reported that they contract with MCOs and submitted 
contracts, staff in OIGs Office of Counsel to the Inspector General 
reviewed the States contracts with MCOs to determine whether they 
included the required provision that providers terminated from Medicare, 
Medicaid, and CHIP be prohibited from participating in each MCOs 
managed care networks.   
For contracts that did not contain the required provision, we calculated 
the total capitation payments each State made for the plans associated 
with these contracts.   
Appendix A provides a more detailed methodology. 
Limitations 
We did not verify the accuracy or completeness of States enrollment 
rosters, States managed care information, State-reported plan IDs, CMSs 
termination data, or T-MSIS data.  T-MSIS data is dynamic and is updated 
by States periodically.  Therefore, the data used for our analyses may be 
subject to future updates.        
States differed in the completeness of their T-MSIS data, which limited 
our analyses.  Therefore, the data does not account for all claims, 
encounter records, and payments associated with terminated providers 
and it does not account for all capitation payments to managed care 
plans under contracts that did not contain the required Cures Act 
provision.   
 
Standards  We conducted this study in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency.   
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FINDINGS 
Eleven percent of  Of the 9,047 terminated providers included in CMSs data, 
963 providersor 11 percent of terminated providerswere still able to 
terminated 
serve Medicaid beneficiaries.17   
providers were still 
Terminated providers inappropriately enrolled in Medicaid.  Five-hundred 
able to serve 
thirty-two terminated providers were still enrolled in State Medicaid 
Medicaid 
programsi.e., included on a State enrollment rosterwhich would allow 
beneficiaries  them to serve Medicaid beneficiaries.  Medicaid made payments 
associated with 153 of these 532 terminated providers.   
Terminated providers associated with inappropriate payments.  
Five-hundred eighty-four terminated providers were associated with 
Medicaid paymentsi.e., associated with claims or encounter records
since July 2018.  Of these 584 terminated providers, 412 were not enrolled 
in Medicaid, 153 were inappropriately enrolled, and 19 were appropriately 
enrolled at the time of our enrollment review.      
Exhibit 1: Terminated providers continued to be enrolled in 
State Medicaid programs and/or associated with Medicaid 
payments 
 
532 terminated   584 terminated 
providers were  providers were 
a 
inappropriately  associated with 
enrolled in  inappropriate 
Medicaid  payments 
 
 
Terminated providers inappropriately  Terminated providers both 
enrolled in Medicaid and not associated  inappropriately enrolled in Medicaid and 
  with payments     associated with payments 
            
Terminated providers associated with 
payments and not enrolled in Medicaid 
     
            
 
Source: OIG analysis of State enrollment rosters from January to May 2019, T-MSIS data from 
July 2018 to June 2019, and CMSs termination database from February 2019. 
a The dates used for our enrollment and payment reviews sometimes differed.  Therefore, there were an 
 
additional 19 terminated providers associated with inappropriate payments that we found to be 
 appropriately enrolled. 
 
17 This 11-percent figure is similar to an earlier OIG finding that 12 percent of Medicaid 
 
providers terminated by one State in 2011 were still enrolled as providers in other States in 
 
2012.  OIG, Providers Terminated from One State Medicaid Program Continued Participating 
in Other States, OEI-06-12-00030, August 2015.  
States Could Do More To Prevent Terminated Providers From Serving Medicaid Beneficiaries  7 
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Six percent of terminated providers were still enrolled in at 
least one State Medicaid program 
Of the 9,047 terminated providers included in CMSs data, 532 (6 percent) 
were enrolled in State Medicaid programs.  As shown in Exhibit 2, most 
States had 20 or fewer terminated providers enrolled in their States 
Medicaid program.   
Exhibit 2: Nearly all States had at least one terminated provider 
enrolled in their State Medicaid programs.a 
 
 
States with 0 terminated providers enrolled in their  States with 1-5 terminated providers enrolled in their 
    Medicaid programs     Medicaid programs 
                 
States with 6-20 terminated providers enrolled in  States with over 20 terminated providers enrolled in 
   their Medicaid programs     their Medicaid programs 
 
               
 
Source:  OIG analysis of State enrollment rosters from January to May 2019, and CMSs termination database from 
February 2019. 
  a Florida also submitted separate rosters of registered individual and organizational providers.  Managed care plans 
screen and credential these providers and send information on these providers to the State.  Because these providers 
  serve Medicaid beneficiaries, we included them in our analysis.   
Of these 532 terminated providers322 individuals and 
210 organizations68 providers were still enrolled in multiple State 
Medicaid programs.  In fact, 1 terminated organization was enrolled in 
28 State Medicaid programs, and 3 additional terminated organizations 
were each enrolled in over 10 State Medicaid programs.   
 
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Nearly one-third of the 532 terminated providers were still enrolled in the 
State that reported the termination.  Thirty-two percent of terminated 
providers (168 of 532 providers) were still enrolled in the State that 
terminated them.  This occurred in 26 States.  For example, 45 of the 
62 terminated providers that we found on Marylands current enrollment 
roster had been reported to CMS as terminated by that State.   
Appendix B provides the number of terminated providers enrolled in each 
States Medicaid program and the number that were terminated by and 
still enrolled in the same State.   
Seventy-one percent of the terminated providers associated 
with Medicaid payments were not enrolled in a Medicaid 
program 
In total, 584 terminated providers were associated with Medicaid 
payments since July 2018.  Of the 584 terminated providers associated 
with Medicaid payments, 412 were not enrolled in a State Medicaid 
program.18  This is despite the fact that States and their MCOs are not 
supposed to pay for services provided, ordered, or prescribed by 
unenrolled providers.19  Therefore, not only did these States and MCOs 
make payments associated with terminated providers, they made 
payments associated with unenrolled providers.   
Payments associated with unenrolled providers may indicate that States 
and their MCOs payment systems did not reject claims and encounter 
records associated with providers not enrolled in Medicaid.  OIGs report 
related to the enrollment requirements mandated by the Cures Act, found 
that 23 States reported allowing unenrolled providers to serve Medicaid 
beneficiaries.20  These lapses represent a significant program integrity 
vulnerability and non-compliance with legal requirements that prohibit 
Federal payments for terminated or unenrolled providers.21   
 
 
 
 
18 Four of these 412 providers had NPIs, SSNs, and/or EINs that appeared on States 
enrollment rosters.  However, the provider name listed on the States enrollment rosters 
did not match the provider name listed in CMSs termination database.  Because of this, 
we did not consider these four providers to be enrolled.  
19 P.L. No. 114-255  5005(a)(4) and (b).  42 CFR part 455, subparts B and E. 
20 OIG, Twenty-three States Reported Allowing Unenrolled Providers to Serve Medicaid 
Beneficiaries, OEI-05-19-00060, March 2020. 
21 P.L. No. 114-255  5005(a)(4) and (b).  42 CFR part 455, subparts B and E. 
 
States Could Do More To Prevent Terminated Providers From Serving Medicaid Beneficiaries  9 
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Medicaid made $50.3 million in payments associated with 
584 terminated providers  
States made $50.3 million in Medicaid payments for nearly 300,000 claims 
and/or encounter records associated with 584 terminated providers.22, 23  
Forty States made these payments for claims and encounter records.24  
Ten of the 40 States accounted for $40.98 million or 81 percent of the 
$50.3 million in payments associated with terminated providers.  
Of the $50.3 million in Medicaid 
Exhibit 3: Medicaid payments 
payments that States allowed for 
associated with terminated 
terminated providers, the State share 
providers totaled $50.3 million. 
totaled $20.1 million and the Federal 
share totaled $30.2 million, as shown 
100%
in Exhibit 3.  Appendix C provides 
State 
information on each States 
share: 
80%
$20.1 payments for claims and encounter 
million records associated with terminated 
60%
providers. 
40% Federal  Fifteen terminated providers 
share: 
accounted for nearly two-thirds of 
$30.2
20% Medicaid payments associated with 
million
all terminated providers.  These 
0% 15 providers (6 individuals and 
Medicaid Payments 9 organizations) were associated 
with $32.4 million of the 
Source:  OIG analysis of T-MSIS data from 
July 2018 to June 2019 and CMSs termination  $50.3 million in Medicaid payments 
database from February 2019. 
associated with terminated 
  providers.  One organizational 
provider alone was linked to $6.1 million in Medicaid payments.   
Appendix D provides additional information on the provider types of the 
terminated providers and the types of services associated with them. 
 
 
 
22 The $50.3 million figure$16.3 million in FFS claims and $34 million in managed care 
capitation paymentsmay understate the financial impact of payments associated with 
terminated providers.  For further explanation regarding the limitations of the payment 
data, please see page 14 and Appendix A.  
23 Because Medicaid pays a monthly capitation payment for managed care, we could not 
determine the portion of the payment specifically related to terminated providers.   
24 Our analyses of T-MSIS data found that seven States did not make any payments for 
claims or encounter records associated with terminated providers. 
States Could Do More To Prevent Terminated Providers From Serving Medicaid Beneficiaries  10 
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Two-thirds of terminated providers who were still able to serve 
Medicaid beneficiaries posed a potential risk to Medicaid 
beneficiaries 
All providers within CMSs termination database have been terminated 
for cause.  The for cause reasons range from Medicaid policy violations 
to more egregious concerns, such as criminal convictions and misconduct.  
Exhibit 4 lists all the termination reasons for the 963 terminated providers 
enrolled in State Medicaid programs and/or associated with Medicaid 
payments. 
Two-thirds of these terminated providers (634 of 963) were terminated for 
(1) criminal convictions, including illegal distribution of drugs; (2) licensure 
issues, such as license loss or suspension; and (3) provider misconduct, 
including unprofessional conduct and patient neglect.  In fact, one provider, 
terminated for patient negligence and inappropriate treatment, was still 
enrolled in nine States Medicaid programs.  Providers terminated for cause 
pose potential risks to beneficiaries safety and quality of care.   
Exhibit 4: The reasons providers were terminated included 
those that may pose a potential risk to Medicaid beneficiaries.a 
Number of Providers  Reason for Termination 
300  Issues related to licensure (loss, suspension, etc.) 
258  Termination/exclusion from a State/Federal health care program 
251  Criminal conviction(s) 
  113  Provider misconduct 
 57  Abuse of billing privileges 
 47  Non-operational provider 
 32  Falsified information 
 18  Medicaid policy violation 
 12  Failure to repay overpayment 
 10  Other  
 
Source:  OIG analysis of State enrollment rosters from January to May 2019, T-MSIS data from 
July 2018 to June 2019, and CMSs termination database from February 2019. 
a The sum of the number of providers is 1,098, rather than 963, because 124 providers were  
terminated for multiple reasons. 
 
 
 
 
 
 
 
 
 
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Only eight States  Of the 42 States that reported contracting with MCOs, only 8 States had 
contracts that all clearly included the required provision that providers 
had managed care 
terminated from Medicare, Medicaid, or CHIP are terminated from all 
contracts that all 
Medicaid managed care networks.25  As shown in Exhibit 5, another 
clearly included the  21 States had contracts that all included some related language but did 
not clearly include the required provision.  For example, some plans 
required provision 
contracts stated that providers that were excluded should be terminated 
that prohibits 
from the Medicaid managed care network.  However, the term exclusion 
terminated  generally refers to exclusion by OIG or exclusion by a State.26  Further, 
providers from  exclusion is not the only reason that a provider might be terminated.  The 
contract language did not make it clear whether the term excluded was 
participating in 
being used to refer to exclusion by OIG or a Stateor was intended as a 
Medicaid managed 
synonym for terminated.     
care networks 
Exhibit 5: Only eight States contracts all clearly included the 
 
provision that the Cures Act requires regarding terminated 
providers. 
8 States contracts clearly included the required 
provision regarding terminated providers 
21 States contracts did not clearly include the 
required provision regarding terminated providers 
8 States contracts did not include the required 
provision regarding terminated providers 
5 States had at least one contract that did not include 
the required provision regarding terminated providers 
or did not clearly include it 
Source:  OIG analysis of State MCO contracts, 2019 
 
None of the contracts in eight States included the required provision, and 
the remaining five States had at least one contract that either did not 
include the required provision or did not clearly include it.  Contracts that 
do not include or do not clearly include the required provision present a 
 
 
25 We considered a State contract to include the required provision if it included language 
stating that the MCO would terminate a Medicaid network provider if that provider were 
terminated from Medicare, Medicaid, or CHIP, even when the contract did not specifically 
include the term CHIP.   
26 Exclusion by OIG refers to exclusion from participation in Federal health care programs 
under sections 1128 or 1128A of the Social Security Act; States may also exclude providers 
from their Medicaid programs under State law or pursuant to 42 CFR  1002.2.  CMS, 
Medicaid Provider Enrollment Compendium,  1.1.2.C.2.  Accessed at 
https://www.medicaid.gov/affordable-care-act/downloads/program-integrity/mpec-
7242018.pdf on August 3, 2018.     
States Could Do More To Prevent Terminated Providers From Serving Medicaid Beneficiaries  12 
OEI-03-19-00070   
vulnerability because they may allow terminated providers to continue to 
serve Medicaid beneficiaries and reduce States ability to enforce legal 
prohibitions on these providers participation in Medicaid managed care 
networks.   
Exhibit 6: Medicaid payments  States paid at least $62.3 billion in 
to plans under contracts that  capitation payments to plans under 
did not include the required  contracts that did not include the 
contract provision totaled 
required provision  
$62.3 billion. 
States paid at least $62.3 billion in 
capitation payments to plans under 
100%
contracts that did not have the required 
State 
80% share:  provision.27  Of the $62.3 billion, the 
$26.3 Federal share was $36 billion, and the 
billion States share was $26 billion, as shown in 
60%
Exhibit 6.   
40% Federal  An additional $45.5 billion was paid to 
share: 
plans under contracts with language that 
$36
20% billion was not definitive enough for us to 
determine whether the provision was 
0% included.  Appendix E provides the 
Medicaid Payments individual States capitation payments 
made to plans under contracts that did 
Source:  OIG analysis of T-MSIS data from 
July 2018 to July 2019 and State MCO  not include or did not clearly include the 
contracts, 2019. 
required provision.  
 
 
  CMS does not check for the required Cures Act provision when 
reviewing States contracts with MCOs 
CMS has developed a Contract Review Tool or checklist to aid in the 
review of States contracts with MCOs, but the checklist does not include a 
check to determine whether the contract includes the required provision 
regarding terminated providers.28  CMS requires States to submit their 
Medicaid MCO contracts for review and approval.  CMS regional staff use 
the checklist to determine whether these contracts meet requirements 
related to such issues as enrollment, payment, and program integrity.  
Although CMS implemented a new checklist in January 2019 and updated 
 
 
27 For beneficiaries covered under Medicaid managed care, Medicaid does not pay 
individually for services rendered; rather, it pays a monthly capitation payment per 
beneficiary to a managed care plan.  The financial amounts provided for contracts 
included in this finding are understated because we did not identify any capitation 
payments in T-MSIS for some State-reported plan IDs.   
28 Although CMS does not check for the required Cures Act provision regarding 
terminated providers, it does check to see whether the contracts include language 
prohibiting MCOs from employing or contracting with excluded providers.  
States Could Do More To Prevent Terminated Providers From Serving Medicaid Beneficiaries  13 
OEI-03-19-00070   
it in April 2019, the checklist still does not include a check for the required 
provision related to terminated providers. 
Most States include a provision in their contracts with MCOs 
that requires MCOs to report to the State any providers that are 
terminated from their networks  
A significant part of Medicaid program integrity involves States ability to 
monitor providers and be aware of any actions that MCOs take against 
those providers.  However, a 2018 OIG report found that MCOs were not 
reporting provider terminations to the State.29  In that report, OIG 
recommended that CMS work with States to clarify the information that 
MCOs are required to report regarding providers that are terminated or 
otherwise leave the MCO network.   
Most States (38 States) reported that they currently include a provision in 
all their contracts requiring MCOs to report to the State any providers 
terminated from their networks.  Three StatesIndiana, New York, and 
South Carolinadid not include this provision in their contracts with 
MCOs.  One State, Wisconsin, had some contracts that contained the 
provision and others that did not include it.   
 
States incomplete  A comprehensive assessment of the financial impact of terminated 
providers on Medicaid was compromised by the lack of complete and 
reporting of 
accurate data in T-MSIS.  As a result, our findings understate the 
required Medicaid 
payments associated with contracts that did not contain the required 
data prevented a  Cures Act provision.  They also may understate the payments associated 
with terminated providers.  These limitations echo previous OIG findings 
comprehensive 
that raised concerns about the completeness of T-MSIS data.30 
assessment of the 
financial impact of  The most significant limitation was related to calculating the financial 
impact related to terminated providers associated with managed care 
terminated 
encounter records.  Entire States had to be removed from our assessment 
providers on 
of the financial impact.  Specifically, Virginia did not report any managed 
Medicaid  care encounter records or capitation payments to T-MSIS for the period 
of our review.  In addition, Kansas did not report any managed care 
 
 
29 OIG, Weaknesses Exist in Medicaid Managed Care Organizations Efforts to Identify and 
Address Fraud and Abuse, OEI-02-15-00260, July 2018.  
30 OIG, Early Outcomes Show Limited Progress for the Transformed Medicaid Statistical 
Information System, OEI-05-12-00610, September 2013; OIG, Status Update: T-MSIS Data 
Not Yet Available for Overseeing Medicaid, OEI-05-15-00050, June 2017; OIG, National 
Review of Opioid Prescribing in Medicaid is Not Yet Possible, OEI-05-18-00480, August 
2019. 
States Could Do More To Prevent Terminated Providers From Serving Medicaid Beneficiaries  14 
OEI-03-19-00070   
capitated payments to T-MSIS for the period of our review even though 
Kansas reported contracting with three MCOs.   
Even when States reported capitation payment data to T-MSIS, the data 
may not have been complete.  In 19 States, we could not identify in 
T-MSIS all the monthly capitation payments for every beneficiary with 
encounter records associated with terminated providers. 
In total, we could not identify monthly capitation payments in T-MSIS for 
nearly 2,000 beneficiaries, or 7 percent of all the beneficiaries we 
identified with encounter records associated with terminated providers.  
Therefore, our financial impact amount of $50.3 million may understate 
the total capitation amount related to encounter records associated with 
terminated providers.   
We also had to exclude certain claims and encounter records from our 
analysis because the T-MSIS record was missing the data necessary to 
perform final action procedures.  These are procedures that, for example, 
adjust claims to the final payment amount and remove duplicate claims.  
For example, Missouris T-MSIS claims and encounter records were 
sometimes missing key variables that we needed to conduct the final 
action procedure. 
In addition, we encountered some limitations determining the 
FFS payments associated with terminated providers.  For example, Virginia 
did not report any claims data to T-MSIS for the period of our review.   
Missing monthly capitation payment data in T-MSIS also had an impact 
on the analysis of capitation payments related to contracts that did not 
include or did not clearly include the required Cures Act provision.  Three 
StatesKansas, Virginia, and North Dakotadid not submit any Medicaid 
managed care capitation payment data during the period of our review.   
   
States Could Do More To Prevent Terminated Providers From Serving Medicaid Beneficiaries  15 
OEI-03-19-00070   
CONCLUSION AND RECOMMENDATIONS 
Despite the Cures Acts requirements that were designed to strengthen 
Medicaid program integrity, terminated providers continue to serve 
Medicaid beneficiaries.  According to our analysis of enrollment rosters 
and Medicaid claims and encounter data, nearly 1,000 terminated 
providers (11 percent of terminated providers) remained enrolled in State 
Medicaid programs and/or were associated with $50.3 million in Medicaid 
payments.  Some of these providers were terminated for criminal 
convictions, licensure issues, and provider misconduct, representing a risk 
to beneficiaries safety and their quality of care.   
Previous OIG work similarly found that 12 percent of Medicaid providers 
terminated by a State were still enrolled in other States and Medicaid paid 
millions to these providers.31  This earlier work, coupled with these latest 
findings, indicates that States and CMS can do more to protect Medicaid 
beneficiaries from terminated providers and prevent millions in 
inappropriate payments associated with these providers.     
Additionally, this analysis identified payments associated with unenrolled 
providers, indicating that States and their MCOs payment systems may 
not have rejected claims and encounter records associated with providers 
not enrolled in Medicaid.  OIGs report Twenty-Three States Reported 
Allowing Unenrolled Providers to Serve Medicaid Beneficiaries similarly 
found that States reported allowing unenrolled providers to serve 
Medicaid beneficiaries and offers recommendations to strengthen efforts 
to prevent unenrolled providers from participating in Medicaid.32  These 
lapses indicate another vulnerability for CMS and States to address.  
Finally, only eight States clearly included in their contracts with MCOs the 
required provision that prohibits terminated providers from participating 
in Medicaid managed care networks.  The missing provision may allow 
terminated providers to continue to serve Medicaid beneficiaries and 
reduce States ability to enforce legal prohibitions on these providers 
participation in managed care networks.  To date, CMS has not ensured 
that all States have the required language in their managed care 
contracts.    
 
 
31 OIG, Providers Terminated from One State Medicaid Program Continued Participating in 
Other States, OEI-06-12-00030, August 2015. 
32 OIG, Twenty-Three States Reported Allowing Unenrolled Providers to Serve Medicaid 
Beneficiaries, OEI-05-19-00060, March 2020. 
 
States Could Do More To Prevent Terminated Providers From Serving Medicaid Beneficiaries  16 
OEI-03-19-00070   
Underlying these findings are limitations to the analyses because States 
did not report all required data to T-MSIS.  Therefore, the data understate 
the payments associated with contracts that did not contain the required 
Cures Act provision and may understate the payments associated with 
terminated providers.  These limitations echo previous OIG findings that 
T-MSIS data is not complete or accurate enough to conduct Medicaid 
oversight.33  We reiterate the importance of ensuring the accuracy and 
completeness of T-MSIS data.     
To protect taxpayer dollars and the beneficiaries served by the Medicaid 
program, we recommend that CMS take the following steps.   
Recover from States the Federal share of inappropriate 
fee-for-service Medicaid payments associated with terminated 
providers  
We will provide CMS with the claims associated with terminated providers 
associated with Medicaid FFS payments.  After reviewing this information, 
CMS should determine whether States made inappropriate payments and 
seek to recover the Federal share of any inappropriate Medicaid FFS 
payments made by States.  
Implement a method to recover from States the Federal share 
of inappropriate managed care capitation payments associated 
with terminated providers   
States made capitation payments to MCOs for items and services 
associated with terminated providers.  CMS stated that it cannot partially 
disallow the Federal share of capitation payments associated with 
terminated providers.  To the extent that CMS determines that it cannot 
partially disallow capitation payments associated with terminated 
providers, CMS should implement an alternative method to recover these 
payments.   
Follow up with States to remove terminated providers that OIG 
identified as inappropriately enrolled in Medicaid 
Barring a compelling access to care concern, CMS should work with States 
to remove the terminated providers we identified as still enrolled from 
their State Medicaid enrollment rosters.  We will provide CMS the list of 
terminated providers enrolled in States Medicaid programs to share with 
 
 
33 OIG, Early Outcomes Show Limited Progress for the Transformed Medicaid Statistical 
Information System, OEI-05-12-00610, September 2013; OIG, Status Update: T-MSIS Data 
Not Yet Available for Overseeing Medicaid, OEI-05-15-00050, June 2017; OIG, National 
Review of Opioid Prescribing in Medicaid is Not Yet Possible, OEI-05-18-00480, August 
2019. 
States Could Do More To Prevent Terminated Providers From Serving Medicaid Beneficiaries  17 
OEI-03-19-00070   
States.  CMS should alert States that these providers are still enrolled and 
inform the States that they should be terminated from enrollment.   
Confirm that States do not continue to have terminated 
providers enrolled in their Medicaid programs 
To prevent future terminated providers from remaining enrolled in State 
Medicaid programs, CMS could work with States to overcome any 
challenges they may face in removing terminated providers from their 
enrollment rosters.  Finally, CMS could conduct periodic reviews 
comparing States enrollment rosters and/or T-MSIS claims and encounter 
records to the termination database to confirm that States efforts to 
remove terminated providers from Medicaid have been effective.   
Safeguard Medicaid from inappropriate payments associated 
with terminated providers 
To ensure that State safeguards effectively prevent inappropriate 
payments, CMS could determine during its payment error rate 
measurement (PERM) process whether States made FFS payments 
associated with providers who should have been terminated.  The PERM 
process measures and reports improper payment rates for Medicaid 
primarily through the review of a sample of paid FFS claims and ensures 
that a State does not make payments to providers terminated by that 
State.  Currently, PERM does not determine whether a State made FFS 
payments associated with a provider who should have been terminated 
because the provider had been terminated in another State.  If PERM were 
to include an assessment of FFS payments associated with providers who 
should have been terminated, this information could help CMS identify 
and recoup the Federal share of funds associated with these providers.  
CMS also could develop and implement other methods to safeguard 
against Medicaid payments associated with terminated providers.  
Review States contracts with managed care organizations to 
ensure that they specifically include the required provision that 
prohibits terminated providers from participating in Medicaid 
managed care networks  
CMS should ensure that States contracts with MCOs specifically and 
clearly include the termination provision by adding a check for this 
required provision to its contract review checklist.   
 
 
 
 
States Could Do More To Prevent Terminated Providers From Serving Medicaid Beneficiaries  18 
OEI-03-19-00070   
AGENCY COMMENTS AND OIG RESPONSE 
CMS concurred with all six of our recommendations and described steps 
to implement each.   
In response to our first recommendation, CMS stated that it will review 
OIGs findings and take appropriate action to determine whether States 
made inappropriate payments and seek to recover the Federal share of 
any inappropriate Medicaid FFS payments made by States, in accordance 
with CMS policies and procedures. 
In response to our second recommendation, CMS stated that it has 
requested legislative authority to reduce States administrative match 
rates for noncompliance with provider screening, enrollment, and 
revalidation requirements in Medicaid and CHIP for both managed care 
and FFS in the Presidents fiscal year 2021 budget.   
In response to our third recommendation, CMS stated that it will share 
the findings of our report with States and offer technical assistance if 
needed.  
In response to our fourth recommendation, CMS stated that it provides 
technical assistance to States to help them overcome challenges in 
removing terminated providers from their Medicaid programs.  CMS also 
noted that it will complete terminated provider desk reviews for all States 
in fiscal year 2020.  In addition, CMS will, upon State request, periodically 
match state enrollment rosters to the termination database and share the 
results with States.  
In response to our fifth recommendation, CMS stated that it conducts 
State program integrity desk reviews of terminated providers.  While 
payments from managed care plans to providers are outside the scope of 
CMSs PERM authority, CMS stated that it will investigate the possibility of 
expanding PERM to include an assessment of a States FFS payments 
associated with providers who have been terminated for cause by another 
State Medicaid or CHIP program, who also should have been terminated 
by the State that made the payment. 
In response to our sixth recommendation, CMS stated that it will add the 
required provision that prohibits terminated providers from participating 
in Medicaid managed care networks to its contract review tool. 
OIG and CMS share the goal of preventing terminated providers from 
serving Medicaid beneficiaries.  We are encouraged by CMSs current 
efforts and plans for ensuring that States achieve this goal.  We look 
forward to receiving CMSs updates and progress on these 
recommendations.  For the full text of CMSs response, see Appendix F.     
  
States Could Do More To Prevent Terminated Providers From Serving Medicaid Beneficiaries  19 
OEI-03-19-00070   
APPENDIX A: Detailed Methodology 
This appendix provides more detailed information on our data collection 
and analyses. 
Data Collection  
States.  We requested the following information from all 50 States and the 
District of Columbia (States): 
  a roster of active and enrolled Medicaid providers including all 
provider identification information such as names, addresses, 
National Provider Identifiers (NPIs), Social Security Numbers 
(SSNs), and State Medicaid IDs.34  This included providers that are 
approved to bill, order, certify, refer, prescribe, render, attend, 
treat, provide items and/or services for Medicaid beneficiaries 
under fee-for-service (FFS) and/or managed care;35 
  whether they contracted with managed care organizations (MCOs) 
to provide services to Medicaid beneficiaries;  
  sections of State contracts (and amendments) with Medicaid 
MCOs that include the provision that providers terminated from 
Medicare, Medicaid, and the Childrens Health Insurance Program 
(CHIP) are terminated from all Medicaid managed care networks; 
and 
  State plan IDs used when submitting capitation payments to 
T-MSIS for all managed care plans within a State. 
CMS.  We obtained the termination database from CMS, which provides a 
list of terminated providers.  This report provides identifying information 
for all terminated providers including NPIs, SSNs, Employer Identification 
Numbers (EINs), names, and the date CMS published the termination 
(published date).  The report also provides the entity that terminated the 
provider and the reason for the providers termination.        
Using CMSs T-MSIS data available in OIGs data warehouse, we obtained 
Medicaid FFS claims and managed care encounter records for all types of 
claims and encounter header records: inpatient, long-term care, 
 
 
34 States rosters of active and enrolled Medicaid providers were from January through 
May 2019.  CMSs termination database was current as of February 2019.   
35 Florida also submitted separate rosters of registered individual and organizational 
providers.  Managed care plans screen and credential these providers and send 
information on these providers to the State.  Because these providers serve Medicaid 
beneficiaries, we included them in our analysis.   
States Could Do More To Prevent Terminated Providers From Serving Medicaid Beneficiaries  20 
OEI-03-19-00070   
pharmacy, and other (which includes physician services).  In addition, we 
obtained data on monthly capitation payments paid by States.   
We performed a final action procedure to identify final action claims, 
encounter records, and capitation records and used these claims and 
records for our analysis.  When data needed to perform the final action 
procedure were missing, we excluded these claims, encounter records, 
and capitation records from our analysis.  Although we were unable to 
perform the final action procedure on the entirety of North Carolinas 
pharmacy claims/encounter records, we did include North Carolinas 
pharmacy claims/encounter records in our analysis.  We conducted an 
additional data-cleaning step on these claims and records.  We identified 
duplicate pharmacy claims/encounter records in North Carolinas data, 
and we removed both instances of the duplicates from our analysis 
because we were unable to determine which claim or encounter record 
was the final action claim or encounter record. 
We obtained all Medicaid final action claims and encounter records 
associated with providers in CMSs terminations database that had an 
admission date (for inpatient claims and encounter records), prescription 
fill date (for pharmacy claims and encounter records), or beginning date 
of service (for long-term claims and encounter records and all other 
claims and encounter records) on or after July 1, 2018 (the 
implementation date for the Cures Act requirements).   
We excluded denied claims and encounter records.  We also removed 
claims and encounter records designated by CMS as supplemental 
payment records, service tracking claims, CHIP claims or encounter 
records, and claims or encounter records designated as other.  
We also collected State Medicaid IDs for terminated providers from the 
provider enrollment file housed in T-MSIS.  We used these State Medicaid 
IDs to identify claims or encounter data associated with terminated 
providers.   
Data Analysis 
Terminated Providers Enrolled in State Medicaid Programs.  The analysis of 
terminated providers enrolled in State Medicaid programs included all 
51 States. 
To determine whether any terminated providers were enrolled in State 
Medicaid programs, we compared the terminated providers in CMSs 
termination database to States enrollment rosters.  Specifically, we 
matched the NPIs, SSNs, and EINs from CMSs termination database to 
the same identifiers in States enrollment rosters.  We confirmed the 
match by reviewing the matched providers names listed in both the State 
rosters and CMSs termination database to ensure that the correct 
provider had been identified in our comparison.   
States Could Do More To Prevent Terminated Providers From Serving Medicaid Beneficiaries  21 
OEI-03-19-00070   
We removed providers from the termination database that were not 
currently terminated as of June 30, 2018.  This resulted in a total of 
9,047 terminated providers.36 
We considered a terminated provider to be inappropriately enrolled in 
Medicaid if the States enrollment rosters as-of date37 was more than 
95 calendar days after the published date in the termination database for 
that provider.  CMS requires States to terminate providers within 
60 business days of the published date.  We used 95 calendar days to 
account for the required 60 business days. 
We determined the total number of terminated providers enrolled in 
Medicaid as well as the number of terminated providers enrolled in each 
State.  We also determined the reason for each providers termination.   
Payments Associated With Terminated Medicaid Providers.  The analysis of 
payments associated with terminated providers did not include all States, 
as shown in Exhibit A-1.  
To determine whether Medicaid paid for items and/or services associated 
with terminated providers, we matched the NPIs and State Medicaid IDs 
for 8,91338 providers in the termination database to the same identifiers 
on the header record of T-MSIS final action claims and encounter 
records.39  This match included all eight NPI fields and all five State 
Medicaid ID fields within the header record.40, 41  Our analysis of Rhode 
 
 
36 For the purposes of our analysis, we determined which providers were in the termination 
database using a unique combination of NPI, SSN, and/or EINdepending on which of 
these variables were available.  We then performed an additional check comparing these 
unique combinations with their associated provider names. 
37 We asked States to provide the date they last updated the information contained in 
their rosters (i.e., the date as of which the information was current).  We refer to this date 
as the as-of date. 
38 For this analysis, we removed 135 terminated providers that had only an EIN listed in the 
termination database.  We did not use EINs to obtain State-specific Medicaid provider IDs 
from T-MSIS because one EIN may be associated with multiple providers.  Without a 
State-specific provider ID, we were unable to match the provider in the database of 
terminated providers to the corresponding claims and encounter records. 
39 The Cures Act prohibits payments associated with terminated providers. However, there 
is an exception made for payments related to emergency items/services not furnished in a 
hospital emergency room.  We requested from CMS any information it would use to 
identify emergency services not provided in an emergency room setting.  However, CMS 
could not provide any codes for items or services that would fall under this exception.  In 
addition, there is no field in T-MSIS that would indicate whether a claim or encounter 
record is related to an emergency item/service not furnished in a hospital emergency 
room.  Therefore, we were unable to determine which items/services would fall under this 
exception. 
40 T-MSIS includes NPIs for eight provider types within the header record: admitting, 
billing, directing, dispensing, health home, prescribing, referring, and supervising. 
41 T-MSIS includes State Medicaid IDs for five provider types within the header record: 
admitting, billing, dispensing, prescribing, and referring. 
States Could Do More To Prevent Terminated Providers From Serving Medicaid Beneficiaries  22 
OEI-03-19-00070   
Islands provider enrollment file as well as its claims and encounter 
records indicated that its State Medicaid IDs may not be correct.  
Therefore, we were unable to identify problematic claims and encounter 
records using State Medicaid IDs for Rhode Island.    
Exhibit A-1: Number of States included in and excluded from 
the analysis of FFS claims and managed care encounter records 
associated with terminated providers  
   
s  Number of States included in this analysis that 
m 50 
submitted FFS claims to T-MSIS 
ai
Cl    
S  Number of States excluded from this analysis because  1a 
F
F they did not submit FFS claims to T-MSIS 
 
 
   
r  Number of States included in this analysis that 
e 42 
nt submitted managed care encounter records to T-MSIS 
ou    
Enc s  Number of States excluded from this analysis because  8b  
e  rd they did not contract with MCOs and did not submit 
r o
Ca ec managed care encounter records to T-MSIS 
d  R  
e
g Number of States excluded from this analysis because  1a 
a
an they contract with MCOs but did not submit any 
M
managed care encounter records to T-MSIS 
 
 
Source: OIG analysis of T-MSIS data from July 2018 to June 2019 and CMSs termination database 
from February 2019. 
a Virginia had not submitted any FFS claims or managed care encounter records to CMS for our 
review period.   
b Alaska, Connecticut, Maine, Montana, Oklahoma, South Dakota, Vermont, and Wyoming.   
 
We included 50 States in our analysis of FFS claims.  FFS claims for one 
State (Virginia) were not included in this analysis because, as of June 2019 
(the date we obtained T-MSIS data for our analysis of claims and 
encounter records), Virginia had not submitted any FFS claims to CMS for 
our review period.   
We included 42 States in our analysis of managed care encounter records.  
Eight States reported that they do not contract with MCOs.42  Managed 
care encounter records for one additional State (Virginia) were not 
included in this analysis because, as of June 2019 (the date we obtained 
T-MSIS data for our analysis of claims and encounter records), Virginia 
 
 
42 These eight States are Alaska, Connecticut, Maine, Montana, Oklahoma, South Dakota, 
Vermont, and Wyoming.  In addition, although Alabama reported that it does not contract 
with MCOs, we included Alabama in our analysis of encounter records because it 
submitted managed care encounter records.   
States Could Do More To Prevent Terminated Providers From Serving Medicaid Beneficiaries  23 
OEI-03-19-00070   
had not submitted any managed care encounter records for our review 
period.   
We considered a claim or encounter record to be associated with a 
terminated provider only if the date of service on the claim or encounter 
record was more than 95 calendar days after the date that the termination 
was published in the termination database.  Because CMS prohibits States 
from making payments for items and services associated with terminated 
providers more than 60 business days after the published date, we used 
95 calendar days to account for the 60 business days. 
We performed additional analyses on long-term care and pharmacy 
claims and encounter records.  For long-term care claims and encounter 
records that were associated with terminated providers, we further 
checked that the admission date occurred 95 calendar days after the 
admitting providers published termination date.  Similarly, for pharmacy 
claims and encounter records that were associated with terminated 
providers, we checked that the date of the prescription occurred 
95 calendar days from the prescribing providers published termination 
date.43   
We then calculated the amount that Medicaid paid for items or services 
associated with terminated providers.  For FFS claims associated with 
terminated providers, we aggregated total Medicaid paid amounts 
(including any adjustments, i.e., negative payment amounts).  For 
managed care encounter records associated with terminated providers, 
we aggregated the monthly Medicaid capitation amounts (including 
negative payment amounts) that States paid for each beneficiary 
associated with these encounter records.  To do this, we matched the 
plan ID and beneficiary ID from the encounter record with the plan ID and 
beneficiary ID listed on the capitation payment records included in 
T-MSIS.  For our payment calculations, we included only Medicaid 
capitation payments that occurred during the same month as the date of 
the encounter record with the terminated provider.   
We did not identify any encounter records associated with the terminated 
providers in 8 of the 42 States with encounter data submissions.  For 21 of 
the remaining 34 States that had encounter records associated with 
terminated providers, we were unable to obtain all the corresponding 
monthly capitation payments.  There were no capitation payments at all 
for Kansas because, as of June 2019 (the date we obtained T-MSIS data 
for our analysis of claims and encounter records), Kansas had not 
submitted any capitation payment data for our review period.  In total, 
 
 
43 This analysis excludes 482 claims and encounter records on which States did not report 
the prescription date.   
States Could Do More To Prevent Terminated Providers From Serving Medicaid Beneficiaries  24 
OEI-03-19-00070   
monthly capitation payment data corresponding to encounter records 
associated with terminated providers did not exist in T-MSIS for 
1,989 beneficiaries, or 7 percent of all beneficiaries whose encounter 
records were associated with a terminated provider.   
To calculate the Federal share for both FFS and capitation payments, we 
applied the States FMAP for fiscal year 2018 or 2019, depending on the 
date of service. 
We also determined the number of claims and encounter records 
associated with terminated providers as well as the number of terminated 
providers that were associated with these claims and encounter records.  
For this analysis, we did not include (1) claims where the Medicaid paid 
amount was less than or equal to zero or (2) encounter records where the 
capitation paid for the month the encounter occurred was less than or 
equal to zero.  We excluded these claims and encounter records because 
we did not want to count claims and encounter records when a State did 
not make a payment.   
Managed Care Contract Provisions.  The analysis of State contracts with 
MCOs did not include all States, as shown in Exhibit A-2.  
Exhibit A-2: Number of States included in and excluded from 
the analysis of States MCO contracts 
   
Number of States included in this analysis that reported contracting 
42 
w  ith MCOs 
   
Number of States excluded from this analysis because they reported  9a 
that they do not contract with MCOs  
 
Source: OIG analysis of State MCO contracts, 2019. 
a Alabama, Alaska, Connecticut, Maine, Montana, Oklahoma, South Dakota, Vermont, and Wyoming.   
 
For the States that reported that they contract with MCOs and submitted 
contracts, Office of Counsel to the Inspector General staff reviewed the 
States contracts with MCOs to determine whether they included the 
required provision that providers terminated from Medicare, Medicaid, 
and CHIP are terminated from all Medicaid managed care networks.  We 
did not include contracts related to CHIP, Primary Care Case Management 
(PCCM) programs, Program for All-Inclusive Care for the Elderly (PACE), 
Prepaid Inpatient Health Plans (PIHPs), and Prepaid Ambulatory Health 
Plans (PAHPs) in our review, as these requirements are not applicable to 
these contracts.  If a State did not specifically indicate that a managed 
care plan was a CHIP, PACE, PIHP, PAHP plan, or a PCCM program, we 
were unable to exclude it from our analysis.   
 
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OEI-03-19-00070   
We determined the number of States that had contracts that: 
  contained the provision required under the Cures Act, 
  did not contain the provision required under the Cures Act, and 
  did not clearly include the provision required under the Cures Act 
(i.e., because of the language in the contract we were unable to 
conclusively determine that the contract contained the required 
provision).  For example, one or more contracts might prohibit 
providers that were excludedrather than terminatedfrom 
participating in a Medicaid managed care network. 
For the 34 States that had contracts that did not include or did not clearly 
include the required provision, we calculated the total capitation 
payments each State made for the plans associated with these contracts.  
We matched State-reported plan IDs to the plan ID on capitation payment 
records in T-MSIS to calculate total capitation payments associated with 
plans that did not clearly include the required provision in their contracts.  
Capitation payments for Kansas and Virginia were not included because, 
as of July 2019 (the date we obtained capitation payments for our analysis 
of contracts), these States had not submitted capitation payment records 
for our review period.  Overall, our total capitation payment amount is 
understated because we did not identify, any capitation payments in 
T-MSIS for some State-reported plan IDs. 
We aggregated Medicaid final action capitation payments (including 
negative payment amounts) for each plan reported in T-MSIS on or after 
July 1, 2018.  For the purposes of our analysis, we did not include CHIP, 
other, or denied capitation payments.  
We then aggregated these capitation payments for each State.  To 
calculate the Federal share for capitation payments, we applied the States 
FMAP for fiscal year 2019.  
We also analyzed State responses about whether their contracts with 
MCOs include a provision that requires MCOs to report to the State any 
providers that the MCO terminates from its network.   
   
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OEI-03-19-00070   
APPENDIX B: Number of Terminated Providers 
Enrolled in Each State Medicaid Program 
Exhibit B-1: Number of Terminated Providers Enrolled in Each State Medicaid Program 
Number of terminated providers still 
Number of terminated providers enrolled  enrolled after the State reported the 
State  in State Medicaid program  termination to CMS 
CA  64  43 
MD  62  45 
FL  51  10 
DE  50  2 
GA  43  1 
AZ  30  0 
WA  28  2 
NM  26  0 
TN  26  0 
WV  25  0 
LA  23  11 
OH  21  6 
MN  20  11 
IL  18  2 
NJ  16  3 
VA  15  0 
IA  12  0 
MO  12  4 
NV  12  5 
IN  11  2 
MI  11  1 
NC  11  2 
WI  11  4 
OK  9  0 
KS  8  0 
PA  8  1 
UT  8  0 
ID  7  0 
continued on next page 
 
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OEI-03-19-00070   
Exhibit B-1: Number of Terminated Providers Enrolled in Each State Medicaid Program 
(continued) 
Number of terminated providers still 
Number of terminated providers enrolled  enrolled after the State reported the 
State  in State Medicaid program  termination to CMS 
MS  7  2 
TX  7  1 
DC  6  0 
AR  5  0 
KY  5  2 
MA  5  3 
NY  5  1 
AL  4  0 
HI  4  0 
NE  4  1 
OR  4  1 
CO  3  0 
SC  3  2 
MT  2  0 
ND  2  0 
RI  2  0 
VT  2  0 
WY  2  0 
AK  1  0 
ME  1  0 
NH  1  0 
SD  1  0 
CT  0  0 
 
Source:  OIG analysis of State enrollment rosters from January to May 2019 and CMSs termination database from February 2019. 
 
   
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APPENDIX C: Medicaid Payments Associated With 
Terminated Providers, by State  
Exhibit C-1: Medicaid Payments Associated With Terminated Providers, by State 
 
Total Medicaid  Federal Share of  State Share of  Number of  Number of 
State  Paymentsa  Payments   Payments  Paid Claims   Encounter Records  
FLc  $14,173,379  $8,699,383  $5,473,996  3,589  55,249 
NYc  $7,621,422  $3,810,711  $3,810,711  1,681  9,085 
GA  $3,992,922  $2,715,352  $1,277,569  17,233  2,042 
MIc  $2,856,588  $1,845,344  $1,011,244  5,100  21,793 
MTb  $2,571,128  $1,682,903  $888,225  6,275  N/A 
TXc  $2,531,533  $1,460,099  $1,071,434  945  3,869 
INc  $2,217,734  $1,461,121  $756,613  1,017  8,406 
OHc  $1,842,636  $1,160,319  $682,317  354  4,541 
PAc  $1,837,709  $955,943  $881,765  595  3,795 
ALb,c  $1,333,241  $955,499  $377,742  7,818  55 
NJc  $998,673  $499,337  $499,337  10  3,192 
MD  $981,148  $490,574  $490,574  4,588  1,865 
WYb  $934,273  $467,137  $467,137  1,700  N/A 
SC  $813,181  $581,427  $231,754  0  1,232 
LAc  $691,063  $442,215  $248,848  72  3,834 
OKb  $618,790  $377,932  $240,858  7,050  N/A 
KY  $588,965  $420,954  $168,012  58  2,707 
MNc  $516,190  $258,095  $258,095  197  1,341 
NC  $487,043  $328,262  $158,781  3,605  27 
NVc  $449,346  $295,015  $154,331  1,539  2,337 
WAc  $445,408  $222,704  $222,704  41  1,958 
ILc  $437,554  $220,989  $216,565  43,281  48,511 
WI  $310,537  $183,366  $127,171  1,748  181 
TNc  $209,531  $137,959  $71,573  1,776  272 
WV  $172,879  $127,414  $45,465  4,359  0 
MS  $143,550  $109,243  $34,307  615  163 
NM  $137,446  $99,267  $38,179  13  237 
CO  $113,403  $56,701  $56,701  1,350  0 
AZc  $98,974  $69,165  $29,809  11  623 
continued on next page 
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OEI-03-19-00070   
Exhibit C-1: Medicaid Payments Associated With Terminated Providers, by State (continued) 
 
Total Medicaid  Federal Share of  State Share of  Number of  Number of 
State  Paymentsa  Payments   Payments  Paid Claims  Encounter Records  
AKb  $87,977  $43,989  $43,989  494  N/A 
HIc  $43,191  $23,288  $19,902  0  2,261 
NE  $14,968  $7,868  $7,100  0  57 
MAc  $11,591  $5,795  $5,795  9  7 
DC  $5,649  $3,954  $1,695  22  5 
CTb  $2,293  $1,147  $1,147  10  N/A 
VTb  $1,763  $943  $820  53  N/A 
UTc  $1,581  $1,109  $471  9  3 
IA  $983  $582  $401  0  4 
NH  $867  $433  $433  1  4 
MO  $44  $28  $16  3  0 
AR  $0  $0  $0  0  0 
CA  $0  $0  $0  0  0 
ID  $0  $0  $0  0  0 
KSd  $0  $0  $0  0  8 
MEb  $0  $0  $0  0  N/A 
NDe   $0  $0  $0  0  1 
OR  $0  $0  $0  0  0 
RI  $0  $0  $0  0  0 
SDb  $0  $0  $0  0  N/A 
DEf  -  -  -  0  10 
VAg  N/A  N/A  N/A  N/A  N/A 
Source:  OIG analysis of T-MSIS data from July 2018 to June 2019 and CMSs termination database from February 2019. 
a The Federal and State share amounts may not sum to the total Medicaid payment amount in a State because of rounding. 
b State reported it does not contract with managed care plans. 
c Some capitation payments are not included in this States Medicaid payments because, as of June 2019 (the date we obtained T-MSIS data for 
our analysis of claims and encounter records), the State had not submitted monthly capitation payments for some of the beneficiaries related to 
encounter records associated with terminated providers. 
d There are no capitation payments included in this States Medicaid payments because, as of June 2019 (the date we obtained T-MSIS data for our 
analysis of claims and encounter records), the State had not submitted capitation records to T-MSIS for our review period. 
e There are no capitation payments included in this States Medicaid payments because, as of June 2019 (the date we obtained T-MSIS data for our 
analysis of claims and encounter records), the State had not submitted monthly capitation payments for any of the beneficiaries related to 
encounter records associated with terminated providers. 
f State reported capitation payments that, in the aggregate, were negative for encounter records associated with terminated providers. 
g There are no claims or encounter records included for this State because, as of June 2019 (the date we obtained T-MSIS data for our analysis of 
claims and encounter records), the State had not submitted any claims or encounter records to T-MSIS for our review period. 
 
 
   
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APPENDIX D: Number of Claims and 
Encounter Records Associated With 
Terminated Providers, by Service Type and 
Provider Type 
Exhibit D-1: Number of Claims and Encounter Records Associated With Each Service Type  
Inpatient  Long term  Other  Pharmacy 
Service Type  services  services  servicesa  services  Total 
Total Number of 
Claims and 
Encounter Records  179  1,849  136,787  158,081  296,896 
Source:  OIG analysis of T-MSIS data from July 2018 to June 2019 and CMSs termination database from February 2019. 
a Includes physician services.   
 
Exhibit D-2: Number of Claims and Encounter Records Associated With Each Provider Type  
Provider Type  Number of claims/encounter recordsa 
Billing provider                       193,763 
Admitting provider                               219 
Referring provider                         43,667 
Health home provider                            5,933 
Supervising provider                           407 
Directing provider                               462 
Dispensing provider                         93,640 
Prescribing provider                         54,420 
Source:  OIG analysis of T-MSIS data from July 2018 to June 2019 and CMSs termination database from February 2019. 
a These numbers do not total 296,896 because a single claim/encounter record could be associated with multiple provider types that were 
terminated.     
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APPENDIX E: Medicaid Payments for Managed 
Care Contracts That Did Not Clearly Include the 
Required Provision That Prohibits Terminated 
Providers From Participating in Managed Care 
Networks  
Exhibit E-1:  Medicaid Payments for Managed Care Contracts That Did Not Clearly 
Include the Required Provision That Prohibits Terminated Providers From Participating in 
Provider Networks  
Total Medicaid 
State  Capitation Paymentsa  Federal Share  State Share 
NYb  $20,228,031,354   $10,114,015,677   $10,114,015,677  
TXb  $19,811,329,921   $11,528,212,881   $8,283,117,040  
OH  $12,197,784,585  $7,695,582,294  $4,502,202,290  
NJ  $6,248,648,969   $3,124,324,484   $3,124,324,484  
 
LA  $5,618,949,959   $3,652,317,473   $1,966,632,486  
TN  $5,564,572,912  $3,665,384,177  $1,899,188,735 
MN  $4,669,409,828  $2,334,704,914  $2,334,704,914 
MI  $4,631,994,938  $2,985,320,737  $1,646,674,200 
INb  $4,608,460,253  $3,039,740,383  $1,568,719,870 
MD  $3,431,563,025  $1,715,781,513  $1,715,781,513 
GA  $3,254,107,693   $2,200,427,622   $1,053,680,071  
NM  $2,733,456,906   $1,975,195,960   $758,260,946  
WA  $2,614,398,943   $1,307,199,472   $1,307,199,472  
SC  $2,416,356,373  $1,720,929,009  $695,427,364 
MSb  $1,957,387,514  $1,495,248,322  $462,139,192 
OR  $1,579,840,491  $988,348,211  $591,492,280 
FLb  $1,380,465,820  $840,289,545  $540,176,275 
WV  $769,730,743   $572,217,834   $197,512,909  
NE  $687,142,458   $361,299,505   $325,842,954  
CO  $612,968,212  $306,484,106  $306,484,106 
NV  $586,348,038   $380,363,972   $205,984,066  
DC  $575,398,016  $402,778,611  $172,619,405 
UT  $530,411,384  $369,749,776  $160,661,608 
continued on next page 
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OEI-03-19-00070   
Exhibit E-1:  Medicaid Payments for Managed Care Contracts That Did Not Clearly 
Include the Required Provision That Prohibits Terminated Providers From 
Participating in Provider Networks (continued) 
Total Medicaid 
State  Capitation Paymentsa  Federal Share  State Share 
AR  $356,203,784  $251,159,288  $105,044,496 
NH  $308,394,700  $154,197,350  $154,197,350 
HI  $188,456,651  $101,615,826  $86,840,825 
IL  $141,974,145  $71,427,192  $70,546,953 
RIb  $44,096,708  $23,181,639  $20,915,068 
ID  $25,169,457  $17,903,035  $7,266,422 
WIb  $17,396,051  $10,328,035  $7,068,015 
MO  $2,605,615  $1,704,072  $901,543 
KSc  N/A  N/A  N/A 
NDc  N/A  N/A  N/A 
VAc  N/A  N/A  N/A 
Source:  OIG analysis of T-MSIS data from July 2018 to July 2019 and State MCO contracts, 2019. 
a The Federal and State share amounts may not sum to the total Medicaid payment amount in a State because of rounding. 
b As of July 2019 (the date we obtained capitation payments for our analysis of contracts), there were no capitation records for some of the 
State-reported plan IDs for plans that did not clearly have the required provision in their State contracts. 
c There are no capitation payments because, as of July 2019 (the date we obtained capitation payments for our analysis of contracts), the State 
had not submitted any Medicaid managed care capitation records to T-MSIS for our review period. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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OEI-03-19-00070   
APPENDIX F: Agency Comments 
   
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OEI-03-19-00070   
ACKNOWLEDGMENTS 
Tanaz Dutia served as the team leader for this study.  Others in the Office 
of Evaluation and Inspections who conducted the study include 
Emily A. Dieckman and Nancy J. Molyneaux.  Office of Evaluation and 
Inspections staff who provided support include Clarence Arnold, Althea 
Hosein, Kevin Manley, and Christine Moritz.  
We would also like to acknowledge the contributions of other Office of 
Inspector General staff, including Mandy Brooks and Lonie Kim.   
This report was prepared under the direction of Linda Ragone, Regional 
Inspector General for Evaluation and Inspections in the Philadelphia 
regional office; and Edward K. Burley, Deputy Regional Inspector General.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
To obtain additional information concerning this report or to obtain 
copies, contact the Office of Public Affairs at Public.Affairs@oig.hhs.gov.  
States Could Do More To Prevent Terminated Providers From Serving Medicaid Beneficiaries  37 
OEI-03-19-00070   
ABOUT THE OFFICE OF INSPECTOR GENERAL 
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  The Office of Audit Services (OAS) provides auditing services for HHS, 
either by conducting audits with its own audit resources or by overseeing 
Services 
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. 
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evaluations to provide HHS, Congress, and the public with timely, useful, 
and Inspections 
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  The Office of Investigations (OI) conducts criminal, civil, and 
administrative investigations of fraud and misconduct related to HHS 
Investigations 
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 
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lead to criminal convictions, administrative sanctions, and/or civil 
monetary penalties. 
Office of Counsel to  The Office of Counsel to the Inspector General (OCIG) provides general 
legal services to OIG, rendering advice and opinions on HHS programs 
the Inspector 
and operations and providing all legal support for OIGs internal 
General 
operations.  OCIG represents OIG in all civil and administrative fraud and 
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OCIG renders advisory opinions, issues compliance program guidance, 
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authorities.