Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

PROVIDERS TERMINATED FROM 

ONE STATE MEDICAID PROGRAM 

CONTINUED PARTICIPATING IN 

OTHER STATES 

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 provider’s participation in its Medicaid program, the provider could 

potentially participate in another State’s Medicaid program, leaving the second State’s 

program vulnerable to fraud, waste, or abuse committed by that provider. To prevent this 

from happening, the ACA requires States to terminate a provider’s 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 the Centers for Medicare & Medicaid Services 

(CMS) 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 CMS’s 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 provider’s participation in Medicaid 

ended, and the amount that Medicaid paid each provider for services performed after the 

provider’s 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 2014. These Medicaid programs paid $7.4 million to 94 providers 

for services performed after each provider’s 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 provider’s 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 Children’s 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 State’s Medicaid 

program, leaving the second State’s 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 

provider’s 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-MedicaidCoordination/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 Children’s Health Insurance Program (CHIP) programs 

revoke a provider’s 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 State’s Medicaid 

program, taking steps to verify a provider’s identity, if it is in question. 

Third, the agency must act appropriately to terminate the provider’s 

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,” (1–3). 

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 Department’s 

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 Provisions–Guidance to States–Section 6501–Termination 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 Provisions—Guidance to States— 

Section 6501—Termination 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 provider’s 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 CMS’s 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 information—such 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 provider’s 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, CMS’s 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, CMS’s 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 State’s 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 State’s 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 provider’s 

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 Medicaid—some 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 provider’s 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 

agency’s 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 provider’s 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 sources—such as Federal and State databases and 

Web sites—can 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 

 Canceled 

 Conviction 

 Credentialing violation 

 Debarment 

 Disciplinary action 

 Exclusion 

 Indictment 

 Licensure modification 

 Revocation 

 Sanction 

 Suspension 

 Termination 

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 provider’s 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 participate—or began 

participating—in 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 provider’s 

participation in Medicaid. If a provider is not in a legal relationship with 

(i.e., enrolled in) a State Medicaid program—as with the previously 

mentioned 91 providers who were not directly enrolled by State Medicaid 

programs—the State may have limited authority to terminate the 

provider’s participation in any of the State’s 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 State’s Medicaid or CHIP programs. 

The other 16 States that used Medicaid managed care required all 

participating providers—both those in managed care plans and those 

participating on a fee-for-service basis—to 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 provider’s professional license can cause 

misunderstanding for some State Medicaid agency staff 

Some State Medicaid agency staff appeared to misunderstand the 

significance of a provider’s 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 provider’s 

licensure status. Although a State board may continue to grant a license to 

a provider, the State agency is nonetheless required to terminate the 

provider’s Medicaid participation based on the provider’s termination for 

cause from Medicare or from another State’s 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 provider’s 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 ACA—where the provider has exhausted all appeal rights, and there 

____________________________________________________________ 

25 OIG, CMS’s 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 temporary—and 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 provider’s 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 provider’s 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 provider’s participation 

from Medicaid, when required under section 6501 of the ACA, is not 

contingent on the provider’s 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 recommendation—that 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 recommendation—that CMS require that State 

Medicaid programs enroll all providers participating in Medicaid managed 

care—CMS 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 recommendation—that CMS furnish guidance to 

State Medicaid agencies that termination is not contingent upon the 

provider’s active licensure status—CMS 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 CMS’s efforts to improve program integrity in the Medicaid 

program. For the full text of CMS’s 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 CMS’s 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 physician’s SSN but did not include the physician’s NPI, we 

compared the physician’s SSN to NPPES and MED to determine and 

verify the physician’s 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 later—in January 2014—to determine whether and 

when each provider’s 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 

Provider Type Number of 

Providers 

Percentage 

(n = 2,539)* 

Physician** 819 32% 

Personal Care Attendant 463 18% 

Mental Health Provider (e.g., Psychologist, Counselor, 

Social Worker, Behavioral Health Worker) 422 17% 

Nurse 200 8% 

Dentist 143 6% 

Nonphysician Practitioner (e.g., Nurse Practitioner, 

Physician Assistant, Certified Registered Nurse Anesthetist, 

Certified Nurse Midwife) 

96 4% 

Therapist (e.g., Physical, Occupational, Speech and 

Language, Respiratory) 51 2% 

Business Owner 50 2% 

Chiropractor 48 2% 

Podiatrist 44 2% 

Business Employee 43 2% 

Nurse’s 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 

Provided Family Members) 3 <1% 

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 

State Number of Participating Providers 

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) 

State Number of Participating Providers 

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 

Provider Type Number of 

Providers 

Percentage 

(n = 295)* 

Physician** 222 75% 

Mental Health Provider (e.g., Psychologist, Counselor, 

Social Worker, Behavioral Health Worker) 33 11% 

Dentist 16 5% 

Nonphysician Practitioner (e.g., Nurse Practitioner, 

Physician Assistant, Certified Registered Nurse Anesthetist, 

Certified Nurse Midwife) 

10 3% 

Ophthalmologist 3 1% 

Podiatrist 3 1% 

Therapist (e.g., Physical, Occupational, Speech and 

Language, Respiratory) 3 1% 

Hearing Service Provider (e.g., Audiologist) 2 <1% 

Acupuncturist 1 <1% 

Nurse’s 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 

State Number of 

Providers Paid* Total Payments 

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 

Provider Type Number of 

Providers 

Percent 

(n = 94)* 

Physician** 78 83% 

Dentist 6 6% 

Nonphysician Practitioner (e.g., Nurse Practitioner, Physician 

Assistant, Certified Registered Nurse Anesthetist, Certified 

Nurse Midwife) 

4 4% 

Mental Health Provider (e.g., Psychologist, Counselor, Social 

Worker, Behavioral Health Worker) 4 4% 

Ophthalmologist 1 1% 

Therapist (e.g., Physical, Occupational, Speech and Language, 

Respiratory) 1 1%

 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 

Notification Database 

(formerly MCSIS)1 

Providers terminated for cause 

from the Medicare, Medicaid, and 

CHIP programs 

State Medicaid agencies and CMS 

staff 

Fraud Investigation 

Database2 

Fraudulent activity and payment 

suspensions related to Medicare 

and Medicaid providers 

State Medicaid agencies and CMS 

staff; Medicare contractors; law 

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 monthly—the data are 

used to deny claims submitted 

from excluded providers 

staff and contractors; other approved 

entities 

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, 

Chain and Ownership 

System7 

Medicare final adverse actions 

(e.g., revocation of billing 

privileges; licensure suspension 

or revocation; exclusion or 

debarment from participation in a 

Federal or State healthcare 

program) 

State Medicaid agencies and CMS 

staff and contractors; providers; 

suppliers; other authorized users 

Sources: 

1 CMS, CPI-B 11-05, ACA Program Integrity Provisions—Guidance to States—Section 6501—Termination 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/ResearchStatistics-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 Provisions—Guidance to States—Section 6501—Termination 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 agency’s data submission. 

Table F-1: Termination Reasons Submitted by State Medicaid 

Agencies 

Termination Reason Number of 

Providers* 

Percentage 

(n = 2,570)** 

Reason listed simply as “termination” 1,021 40% 

State regulation cited 611 24% 

License suspension, revocation, surrender, or other State 

action 329 13% 

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 

improper billing concerns 5 <1% 

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 

State Yes No 

Did Not 

Use 

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) 

State Yes No 

Did Not 

Use 

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 


~!P-Vlc:~.~ l-4­ DEPARTMENT OF HEALTH Centers for Medicare & Medicaid Services & HUMAN 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 of any 

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 of all 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 OIG’s 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.