Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

CMS’S PROCESS FOR SHARING 

INFORMATION ABOUT 

TERMINATED PROVIDERS 

NEEDS IMPROVEMENT 

Daniel R. Levinson 

Inspector General 

March 2014 

OEI-06-12-00031 
 

 

EXECUTIVE SUMMARY: 

CMS’s Process for Sharing Information About Terminated Providers Needs 

Improvement 

OEI-06-12-00031 

WHY WE DID THIS STUDY 

The Patient Protection and Affordable Care Act (ACA) requires the Centers for Medicare 

& Medicaid Services (CMS) to establish a process for sharing information about terminated 

providers. To meet this requirement, CMS established a Web-based portal, the Medicaid 

and Children’s Health Insurance Program State Information Sharing System (MCSIS). 

Sharing terminated provider data among States prevents terminated providers in one State 

from enrolling in another State. CMS and State agencies can submit information about 

providers that meet CMS’s criteria for having been terminated “for cause” from Medicare, 

Medicaid, or the Children’s Health Insurance Program (CHIP). State Medicaid agencies can 

use these data to identify these providers and subsequently terminate them from their 

Medicaid programs as required under another section of the ACA. In November 2013, 

subsequent to the timeframe we examined for this study, CMS revised its process for sharing 

information about terminated providers. The findings and recommendations in this report 

remain relevant to the new process. 

HOW WE DID THIS STUDY 

We examined all provider records contained in MCSIS as of June 1, 2013. We 

(1) determined the extent to which CMS and State Medicaid agencies submitted records to 

MCSIS; (2) identified records that did not meet CMS criteria for reporting providers 

terminated “for cause” from Medicare, Medicaid, or CHIP; and (3) assessed whether records 

had complete identifying information about providers, including National Provider 

Identifiers (NPIs), provider types, and provider addresses. 

WHAT WE FOUND 

As of June 1, 2013, MCSIS contained records on terminated providers submitted by CMS 

and 33 State Medicaid agencies and did not contain records from the remaining State 

Medicaid agencies. Contrary to CMS guidance, about one-third of the 6,439 records in 

MCSIS did not relate to providers terminated “for cause.” Over half of MCSIS records did 

not contain NPIs, a critical data element for accurately identifying providers. Additionally, 

one-third of MCSIS records did not identify the provider types and one quarter had no 

provider addresses. 

WHAT WE RECOMMEND 

Our findings suggest that CMS’s process for sharing information on terminated providers 

needs improvement to make it more useful to State Medicaid agencies in identifying 

providers that must be terminated pursuant to Federal law because they were terminated “for 

cause” by Medicare, Medicaid, or CHIP. Therefore, we recommend that CMS (1) require 

each State Medicaid agency to report all terminated providers, (2) ensure that the shared 

information contains only records that meet CMS’s criteria for inclusion, and 

(3) take action to improve the completeness of records shared through the process. CMS 

concurred with all recommendations. 
 

TABLE OF CONTENTS 

Objectives.................................................................................................... 1 

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

Methodology ............................................................................................... 5 

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

CMS and 33 State Medicaid agencies submitted records on 

terminated providers to MCSIS; the remaining State agencies 

did not submit such records .............................................................. 7 

Almost one-third of records contained in MCSIS did not relate 

to providers terminated “for cause” ................................................ 7 

Over half of MCSIS records did not contain NPIs or other 

identifying information ................................................................... 9 

Conclusion and Recommendations ........................................................... 13 

Agency Comments and Office of Inspector General Response ................ 15 

Appendix ................................................................................................... 16 

A: MCSIS Records, as of June 1, 2013........................................ 16 

B: Agency Comments................................................................... 21 

Acknowledgments ..................................................................................... 24 
 

 

 

OBJECTIVES 

1.	 To determine the extent to which the Centers for Medicare 

& Medicaid Services (CMS) and State Medicaid agencies 

(State agencies) reported provider information to the Medicaid and 

Children’s Health Insurance Program State Information Sharing 

System (MCSIS). 

2.	 To identify MCSIS records not related to providers terminated “for 

cause” from Medicare, Medicaid, or the Children’s Health Insurance 

Program (CHIP). 

3.	 To assess the completeness of provider identifying information in 

MCSIS records, including National Provider Identifier (NPI), provider 

type, and provider address. 

BACKGROUND 

Section 6401(b)(2) of the Patient Protection and Affordable Care Act 

(ACA) requires CMS to establish a process to make available to State 

agencies information about individuals and entities1 terminated from 

participating in the Medicare, Medicaid, or CHIP programs.2 To meet this 

requirement, CMS established MCSIS, a secure Web-based portal, used 

for the specific purposes of storing information about terminated providers 

and making that information available to State Medicaid agencies.3 

During interviews, CMS officials indicated that they expected MCSIS to 

be a temporary database for use while CMS developed a more permanent 

process for sharing data on terminated providers. In November 2013, 

subsequent to our data collection and analysis for this report, CMS revised 

the process and moved the function of sharing information about 

terminated providers from MCSIS to another automated system. Although 

this report focuses on MCSIS, its findings and recommendations are 

applicable to the revised process. 

Section 6401(b)(2) of the ACA specifies that the process for sharing 

information on terminated providers must include the name of the 

1

 76 Fed. Reg. 5862, 5943 (Feb. 2, 2011). CMS interpreted the term “individuals and 

entities” to include providers, suppliers, and eligible professionals. In this report, we use 

the term “provider” to refer to providers, suppliers, and eligible professionals. 2

 ACA, P.L. 111-148 § 6401(b)(2) (Mar. 23, 2010), as amended by the Health Care and 

Education Reconciliation Act of 2010, P.L. 111-152 (Mar. 30, 2010). 3

 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. 

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terminated provider, the provider’s NPI,4 and other identifying 

information. Access to this information can assist State agencies in 

complying with section 6501 of the ACA, which requires State Medicaid 

programs to terminate participation of providers if terminated under 

Medicare, another State Medicaid program, or CHIP.5, 6 

ACA Provider Termination Requirement 

Section 6501 of the ACA requires that, effective January 1, 2011, each 

State must terminate the participation of any individual or entity from the 

State Medicaid program if that provider or entity’s participation has been 

terminated from Medicare, another State Medicaid program, or CHIP.7 

Terminations occur when: 

	 Medicare, Medicaid, or CHIP programs revoke a provider’s billing 

privileges, 

	 the provider has exhausted all applicable appeal rights or the 

timeline for such appeal has expired, 

	 there is no expectation by any party that the termination is 

temporary, and 

	 the provider would be required to reenroll to have billing privileges 

reinstated.8 

The requirement for States to terminate applies only in cases when 

providers, suppliers, or eligible professionals were terminated or had their 

billing privileges revoked “for cause.” “For cause” terminations, as 

defined by CMS in implementing regulations, means terminations or 

revocations of billing privileges for reasons that may include, but are not 

limited to, fraud, integrity, or quality.9 “For cause” terminations do not 

include State program removal of inactive providers from provider 

enrollment files or cases when providers voluntarily end their participation 

4

 69 Fed. Reg. 3434, 3440 (Jan. 23, 2004). The NPI is a standardized Federal unique
 

identifier for individual and organizational health care providers. Federal regulations 

require an NPI for transmitting health information electronically for Medicare and 

Medicaid services. 

5

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

6

 76 Fed. Reg. 5862, 5943 (Feb. 2, 2011). Although section 6501 of the ACA does not 

specifically require terminations of CHIP providers, CMS included such terminations
 

from CHIP in Federal regulations.
 7

 ACA § 6501, SSA § 1902(a)(39), 42 U.S.C. § 1396a(a)(39). 

8

 Ibid. 42 CFR § 455.101.
 9

 76 Fed. Reg. 5862, 5943 (Feb. 2, 2011). 42 CFR § 455.416(c). CMS, CPI-B 12-02, 

ACA 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. CMS provided examples of “for cause” terminations, some of 

which are fraudulent conduct, abuse of billing privileges, misuse of billing numbers, 

falsification of medical records, and falsification on enrollment applications. 

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in the program, except when a provider takes this voluntary action to 

avoid a sanction, such as revocation or termination.10 

Submitting Records to MCSIS 

CMS made MCSIS available to accept submissions of records in 2011. 

CMS could submit records about providers terminated from Medicare, and 

State agencies could submit records about providers terminated from 

Medicaid or CHIP. CMS and State agencies could submit records by 

uploading or manually entering records into the database, and they could 

edit previously submitted records.11 Neither Federal law nor CMS policy 

requires States to submit records about terminated providers to CMS. 

However, CMS encouraged State agencies to submit such records to 

MCSIS and thus make information about terminated providers available to 

other State agencies to facilitate compliance with section 6501 of the 

ACA.12 CMS clarified to State agencies that “for cause” terminations 

shared with other States “should be limited to terminations based upon 

fraud, integrity, or quality.”13 Although CMS did not verify the 

information that State agencies submitted to MCSIS, it issued a User 

Manual with instructions to State agencies for submitting records to 

MCSIS.14 

Using Information Contained in MCSIS 

If State agencies submitted records to MCSIS as CMS encouraged them to 

do, other State agencies could use the information stored in MCSIS to 

identify providers that they must terminate from Medicaid pursuant to 

section 6501.15 To obtain information, a State agency could either search 

MCSIS for particular providers or export the MCSIS database to conduct 

“matches” against the State agency’s roster of providers. These data 

matches could identify providers by name and further verify possible 

matches by checking the NPI or other identifying information, such as 

provider type and address. The more data elements that matched, the 

10 Ibid. 

11 CMS, CPI-B 12-02, ACA 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.
 12 Section 1902(a)(41) of the SSA, 42 U.S.C. § 1396a(a)(41), requires broadly that all 

Medicaid State plans “provide that whenever a provider of services or any other person is 

terminated, suspended, or otherwise sanctioned or prohibited from participating under the 

State plan, the State agency shall promptly notify the Secretary and, in the case of a 

physician and notwithstanding paragraph (7), the State medical licensing board of such 

action.” 

13 Ibid. 

14 CMS, CMS Medicaid and Children’s Health Insurance Program (CHIP) State 

Information Sharing System (MCSIS) User Manual. Initial publication Version 1.0,
 

January 14, 2011; Version 2.9 published June 9, 2012.
 15 76 Fed. Reg. 5862, 5943 (Feb. 2, 2011). 42 CFR § 455.416(c). 

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greater the confidence a State agency could have that it identified the same 

provider terminated “for cause” by Medicare or another State program. 

MCSIS Data Fields 

MCSIS contained multiple data fields for storing information about 

terminated providers. These fields included the two data elements 

specifically required by the ACA: provider name and NPI.16 The ACA 

specifically requires CMS’s information-sharing process to include NPI, 

which is the primary provider identifier used for submitting claims to 

Medicare, Medicaid, and many other health care payers. However, not all 

types of providers are required to have an NPI (e.g., home health aides), 

meaning that an NPI may not have been available for every record 

submitted to MCSIS.17 MCSIS contained additional fields that captured 

other information, such as provider type, provider address, and the name 

of the reporting State. MCSIS also included fields associated with the 

provider’s termination, including termination date, length of termination, 

reason for termination, and program from which the provider was 

terminated (i.e., Medicare, Medicaid, or CHIP).18 

Seven MCSIS data fields, shown in Table 1, were mandatory, meaning 

that record submissions had to contain information in those fields to be 

accepted into the database. MCSIS would reject a record submitted with 

any mandatory fields empty.19 

Three fields shown in Table 1 were optional; MCSIS would accept a 

submission that did not contain information for NPI, provider type, and/or 

State provider ID. 

Some fields in MCSIS offered drop-down menus with a list of choices. 

For example, MCSIS had 14 choices for the reason for a provider’s 

termination, such as abuse of billing privileges, felony conviction, and 

State exclusion/debarment. The field for provider type included 

26 choices, such as Physician, Nonphysician Practitioner, and Home 

Health Agency, as well as “Other.” Additional fields with drop-down 

menus included the terminating program (i.e., Medicare, Medicaid, or 

CHIP) and the code for the reporting State. 

16 ACA § 6401(b)(2).
 17 45 CFR § 162.103, § 162.404, § 162.410. NPIs are required only for health care
 

providers satisfying the Health Insurance Portability and Accountability Act’s (HIPAA’s) 

definition of covered entities, which means (1) a health plan, (2) a health care 

clearinghouse, or (3) a health care provider that transmits health information in electronic 

form in connection with a transaction covered by HIPAA. Thus, some providers are not
 

required to obtain an NPI because they do not meet this definition. 

18 MCSIS contained a few other data fields that were not relevant for purposes of this
 

report.
 19 CMS, MCSIS User Manual, Version 2.9, June 9, 2012, p. 61. 

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Table 1: Selected Data Fields Available for Records in MCSIS 

Terminated Provider Information Mandatory Optional 

Name (Individual or Organization) X 

NPI X 

Other Identifying Information:

 Address (Mailing/Practice) X 

 Provider Type X 

State Code X 

 State Provider ID X 

Termination Information: 

 Length of Termination X 

 Program Type (Medicare, Medicaid, or CHIP) X 

 Termination Date X 

 Termination Reason X 

Source: CMS MCSIS User Manual, Version 2.9, June 9, 2012. 

METHODOLOGY 

Scope 

For this report, we examined all records contained in MCSIS as of 

June 1, 2013. We identified the extent to which MCSIS contained records 

from CMS and State agencies about providers terminated “for cause” from 

Medicare and from Medicaid. We also examined the completeness of 

information in MCSIS data fields and attempted to verify the accuracy of 

submitted NPIs. This report focuses on records contained in MCSIS. A 

separate Office of Inspector General (OIG) report (forthcoming) will 

address State agencies’ termination of providers pursuant to section 

6501.20 

Data Collection and Analysis 

To examine records contained in MCSIS, we first identified the number of 

records submitted by CMS and State agencies. We calculated the 

percentage of records associated with Medicare and Medicaid providers.21 

We also examined the reason for termination listed in each record to 

identify any terminated providers not related to “for cause” terminations. 

To assess the completeness of records contained in MCSIS, we examined 

the contents of each data field for each record. We calculated the 

percentages of complete fields and empty fields, across all records and by 

the reporting entity. When records contained “N/A” in a data field, which 

20 OIG, OIG Workplan, Fiscal Year 2013; OIG, State Terminations of Providers 

Terminated by Medicare or by Other States, OEI-06-12-00030, publication expected in 

2014. 

21 At the time of our review, June 1, 2013, MCSIS did not contain any CHIP records. 

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could be an indication that the information was not available or not 

applicable, we considered these data fields to be empty. 

To the extent possible, we verified the accuracy of the NPIs contained in 

MCSIS. For this analysis, we compared the NPI contained in MCSIS to 

the NPI listed for the provider in CMS’s National Plan and Provider 

Enumeration System (NPPES), the database that CMS uses for assigning 

NPIs to individual providers and entities.22 

Limitations 

This study has two limitations. First, with the exception of the NPIs, we 

did not verify the accuracy of the information submitted to MCSIS. 

Second, given the temporary status of MCSIS and the voluntary 

participation by State agencies, we did not attempt to determine the extent 

to which MCSIS contained records for all providers terminated “for 

cause.” 

Standards 

This study was conducted in accordance with the Quality Standards for 

Inspection and Evaluation issued by the Council of the Inspectors General 

on Integrity and Efficiency. 

22 CMS (Medicare Learning Network), The National Provider Identifier (NPI): What 

You Need to Know. Accessed at http://www.cms.gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNProducts/downloads/NPIBooklet.pdf on April 28, 2013. 

CMS developed the NPPES to assign unique identifiers to providers, and CMS stores this 

information in a searchable database known as the NPI Registry. To avoid assigning the 

same NPI to more than one provider, the NPPES tracks individual providers using unique 

personal identifiers, such as date of birth (DOB), place of birth, Social Security number 

(SSN), and Taxpayer Identification number (TIN). 

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FINDINGS 

MCSIS contained records on terminated providers 

submitted by CMS and 33 State Medicaid agencies and 

did not contain records from the remaining State 

Medicaid agencies 

As of June 1, 2013, MCSIS contained 6,439 provider records submitted by 

CMS and 33 State agencies. CMS submitted 27 percent of MCSIS 

records (1,726) about providers terminated from Medicare. Combined, the 

33 State agencies submitted the remaining 73 percent (4,713) of records. 

Four States accounted for 72 percent (3,413 of 4,713) of the Medicaid 

records contained in MCSIS: California (2,074), New York (597), 

Pennsylvania (442), and Illinois (300). See Appendix A, Table A-1, for 

the number of provider records submitted by CMS and State agencies. 

MCSIS did not contain records from the remaining State agencies as of 

June 1, 2013. CMS policy does not require State agencies to submit data 

on terminated providers through CMS’s information-sharing process. 

Almost one-third of records contained in MCSIS did 

not relate to providers terminated “for cause” 

Of the 6,439 records contained in MCSIS, over 2,000 records did not 

relate to providers terminated “for cause.” As mentioned above, CMS 

provided guidance with criteria about “for cause” terminations and 

specified that the information shared in MCSIS should be limited to 

providers terminated “for cause.” However, many records in MCSIS 

pertained to individuals who were not enrolled in or had not been 

terminated from the Medicaid program in the States submitting the 

records, and others pertained to providers whose termination from 

Medicare did not meet CMS’s criteria for “for cause” termination. 

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California submitted records to MCSIS for providers that were 

not enrolled in and had not been terminated from the State 

Medicaid program 

California submitted numerous records (2,000 or more)23 for providers that 

were not enrolled in the Medicaid program. Therefore, these providers 

were not terminated “for cause” and would not warrant termination by 

another State Medicaid program pursuant to section 6501. When 

contacted, State agency officials explained that the agency deemed these 

individual providers and organizations ineligible for enrollment in the 

State Medicaid program.24 Although these officials recognized that the 

records the agency had submitted to MCSIS did not meet the criteria for 

provider terminations, they explained that they wanted to make other State 

agencies aware of the providers’ status as ineligible for enrollment in 

California. 25 

CMS submitted records to MCSIS for deceased providers that 

were not terminated “for cause” 

Of the Medicare provider records submitted to MCSIS, 4 percent (71 of 

1,726) pertained to providers listed as deceased. CMS provides a 

disclaimer in MCSIS acknowledging that deceased providers do not meet 

the guidance it issued regarding “for cause” terminations for purposes of 

section 6501. The disclaimer indicates that States should use the 

information to ensure that they are not paying for services billed on behalf 

of deceased providers.26 See Appendix A, Tables A-2 and A-3, for 

termination reasons submitted to MCSIS by Medicare and State agencies. 

23 It is not possible to determine precisely how many of the 2,074 records submitted by 

the California Medicaid program pertained to providers that were not enrolled and had 

not been terminated. However, State agency officials indicated that, by the definition of 

“suspended and ineligible,” the vast majority of these providers were not participating in, 

and had not been terminated from, Medicaid. 

24 State of California Welfare and Institutions Code, §§ 14043.6 and 14123. 25 We followed up with officials in California on this issue because MCSIS contained so 

many California records. However, we did not contact the other State agencies about this 

issue because it was beyond the scope of the planned data collection for this report. 

Other State agencies may also have submitted records for providers that were not 

terminated “for cause.” 

26 MCSIS contains the following disclaimer about records for deceased providers: “In 

addition to sharing information regarding Medicare providers that have had their 

Medicare billing privileges revoked ‘for cause,’ CMS will also be sharing information 

about providers that have had their Medicare billing privileges deactivated because our 

data indicates they are deceased. While the requirement of section 6501 of the 

Affordable Care Act do not apply per se, States should use the information regarding 

deceased providers to ensure they are not paying for any services that were billed as if 

they were rendered by such deceased providers. Providers that have had their Medicare 

enrollment deactivated due to death will be designated as ‘deceased provider’ under the 

‘reason for termination.’” 

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Over half of MCSIS records did not contain NPIs or 

other identifying information 

Although all MCSIS records included the name of a provider, many 

records did not contain information that would be useful when State 

agencies attempt to identify providers required to be terminated by 

section 6501. Key information missing from MCSIS records included 

NPI, provider type, and address. Overall, 59 percent (3,831 of 6,439) of 

MCSIS records were blank (i.e., contained no information) for at least 1 of 

these fields. 

Over half of records in MCSIS did not contain NPIs, and some 

NPIs appeared to be inaccurate 

Overall, 59 percent (3,771 of 6,439) of MCSIS records did not contain 

NPIs. Most provider types (e.g., physicians, nurse practitioners, home 

health agencies) must have NPIs to bill Medicare and Medicaid, 

suggesting that submitters omitted the NPIs from many of these records.27 

For 15 State agencies, more than 50 percent of submitted records did not 

contain NPIs. 

The remaining 41 percent of MCSIS records contained an NPI. All 

1,726 records submitted by CMS for Medicare providers contained NPIs, 

as did all records submitted by 8 States. See Table 2 for the number and 

percentage of MCSIS records without NPIs. 

Additionally, 3 percent (93 of the 2,668) of NPIs in MCSIS records 

appeared to be inaccurate when compared to NPI data contained in 

NPPES, the database that CMS uses for assigning NPIs to individual 

providers and entities. Three percent (73) of the NPIs in MCSIS were 

listed in NPPES as belonging to different providers, and another 1 percent 

(20) of the NPIs in MCSIS did not match any provider in NPPES. Both 

Medicare and Medicaid provider records had NPI inaccuracies in MCSIS. 

27 It was not possible to confirm whether some provider records in MCSIS legitimately 

did not include NPIs, such as records involving types of providers that are not required to 

obtain NPIs, because many of the records missing NPIs were also missing information on 

the provider types. 

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Table 2: Number and Percentage of MCSIS Records Without NPIs, by

Program Type 

State Medicaid 

Program Number Without NPI Total Records 

Percentage of MCSIS 

Records 

Lacking NPI 

CA 2,018 2,074 97% 

NY 399 597 67% 

PA 333 442 75% 

IL 300 300 100% 

AL 167 190 88% 

OH 128 263 49% 

NJ 100 159 63% 

AR 92 93 99% 

MD 65 122 53% 

NE 40 43 93% 

MI 24 146 16% 

IA 20 21 95% 

AK 16 16 100% 

ID 15 22 68% 

VT 13 14 93% 

MS 10 32 31% 

FL 8 9 89% 

GA 7 20 35% 

MO 3 18 17% 

VA 3 6 50% 

ME 3 4 75% 

AZ 2 12 17% 

CT 2 5 40% 

IN 2 4 50% 

WI 1 43 2% 

WA 0 18 0% 

NV 0 18 0% 

DE 0 14 0% 

KS 0 2 0% 

MA 0 2 0% 

TN 0 2 0% 

LA 0 1 0% 

RI 0 1 0% 

Medicaid Total 3,771 4,713 80% 

Medicare Total 0 1,726 0% 

Medicare and 

Medicaid Total 3,771 6,439 59% 

Source: OIG analysis of MCSIS data as of June 1, 2013. 

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One-third of MCSIS records did not contain provider type 

information, and many other records listed the provider type 

as “Other” 

Although MCSIS offers a drop-down menu for selecting the type of 

provider for each record, the provider type field was blank for 33 percent 

(2,107) of MCSIS records. Fourteen State agencies submitted the records 

with missing provider type information.28 Another 19 percent of records 

(1,221) contained “Other” in the provider type field, potentially making 

these records less useful for verifying database matches. (See Table 3.) 

Programs with records listing the provider type as “Other” included both 

Medicare (355 records) and Medicaid (866 records). The “Other” label is 

appropriate for records that do not fit under any of the other 25 specific 

provider type choices in the drop-down menu. However, it is possible that 

some States overused the “Other” label. For example, Arkansas used 

“Other” in 95 percent of its submitted records (88 of 93), and Florida did 

so for 78 percent of its records (7 of 9). See Appendix A, Tables A-4 and 

A-5, for listings of provider types submitted to MCSIS by Medicare and 

State agencies. 

Table 3: Total Number and Percentage of MCSIS Records by
 

Contents of Provider Type Field
 

Provider Type Records Percentage 

Provider Type Was Listed (Not Listed 

as “Other”) 3,111 48% 

Blank 2,107 33% 

Provider Type Listed As “Other” 1,221 19% 

Total 6,439 100% 

Source: OIG analysis of MCSIS data as of June 1, 2013. 

Among records that contained information on provider type, “physician” 

was the most common provider type listed, indicated in over 30 percent of 

the records. The only other provider types accounting for more than 1 

percent of MCSIS records were Nonphysician Practitioners (5.8 percent), 

Personal Care Attendants (3.8 percent), Psychologists (1.7 percent), 

Dentists (1.6 percent), and Pharmacists (1.2 percent). 

28 California records accounted for 97 percent (2,049 of 2,107) of the records missing 

provider type information. 

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Almost one-quarter of MCSIS records did not contain 

addresses for the providers 

Although MCSIS includes fields for reporting an individual’s practice 

address, a business address, or both, 22 percent of MCSIS records (1,448) 

contained neither.29 California submissions accounted for all the records 

without addresses and instead contained “N/A” (presumably meaning “not 

applicable”) in address fields. 30 The remaining 78 percent of records 

contained addresses, with street numbers or P.O. box numbers, cities, 

States, and ZIP Codes. 31 Our review did not attempt to verify the 

accuracy of the address information contained in MCSIS records. 

29 As mentioned earlier, the address field in MCSIS was a mandatory data field. 

However, it appeared that MCSIS accepted submissions as long as the records contained 

any characters typed in the provider or organization address field. 

30 A small number (62 of 6,439) of the records from States other than California 

contained somewhat incomplete address information, such as containing only the name of 

an institution or facility or missing street numbers or cities. 

31 As a result of rounding, the total number of records without addresses (23 percent) and 

total with addresses (78 percent) do not sum to 100 percent. 

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CONCLUSION AND RECOMMENDATIONS 

As required by the ACA, CMS established a process for sharing 

information about terminated providers by creating MCSIS, a Web-based 

portal. Our findings suggest that CMS’s information-sharing process 

needs improvement to make it useful to State agencies to identify 

providers that the States must terminate from Medicaid pursuant to 

section 6501. Although CMS and 33 State agencies submitted over 

6,400 provider records to MCSIS, the remaining State agencies had not 

submitted any records on terminated providers as of June 1, 2013. 

Further, many of the records contained in MCSIS did not relate to 

providers terminated “for cause,” a requisite factor for State termination 

under section 6501. Moreover, many MCSIS records had empty data 

fields, including fields critical for identifying providers, including NPI, 

provider type, and address. 

Although CMS recently revised its process for sharing information about 

terminated providers, our findings are applicable to the revised process. 

To maximize the usefulness of its process, CMS should address the issues 

identified in this report. 

Therefore, we recommend that CMS: 

Require each State Medicaid agency to report all terminated 

providers 

As directed by section 6401(b)(2) of the ACA, CMS established a process 

to make available information about health care providers that State 

Medicaid agencies must terminate under section 6501 of the 

ACA. However, we found that many State agencies did not submit 

information about any providers terminated from their programs during 

the period that we reviewed: as a result, MCSIS included only a portion of 

providers terminated “for cause.” 

To date, CMS has encouraged, rather than required, State agencies to 

submit terminated provider records. However, CMS has broad authority 

under section 1902(a)(41) of the SSA to require State agency reporting of 

information about terminated providers. CMS should use this authority to 

ensure that the process established under section 6401(b)(2) of the ACA 

includes all providers terminated by State and Federal programs for 

reasons involving fraud, integrity, or quality. 
 

 

 

Ensure that the shared information contains only records that 

meet CMS criteria for inclusion 

To date, CMS guidance has been clear that terminations shared through its 

information-sharing process should be limited to “for cause” terminations 

for reasons involving fraud, integrity, or quality. By definition, “for 

cause” terminations are not final until the provider has exhausted all 

applicable appeal rights or the timeline for such appeal has expired. To 

ensure that its information-sharing process does not include inappropriate 

records, such as those for individuals who were not enrolled or who had 

not been terminated, CMS should adhere to its criteria and remove any 

existing records that do not meet the criteria. Such actions would assure 

State agencies that the providers listed as terminated “for cause” must be 

terminated under section 6501. Further, because deceased providers do 

not meet the criteria for “for cause” termination, CMS should remove the 

Medicare records for deceased providers from its information-sharing 

process. We do not recommend a change in criteria for submissions. Still, 

if CMS chooses to include records for deceased providers or to otherwise 

expand its information-sharing process beyond “for cause” terminations, it 

should issue new regulations or guidance and implement a mechanism to 

clearly identify those providers that a State must terminate under section 

6501. 

Take action to improve the completeness of records shared 

through the process, especially in data fields critical to 

identifying terminated providers 

Incomplete records—especially those missing NPIs, provider types, and 

addresses—make CMS’s information-sharing process far less useful to 

States attempting to identify providers that warrant termination under 

section 6501. Without at least some of this essential information, data 

matches of State provider rosters against CMS’s data would likely require 

confirmation using other sources. To improve the quality of records, CMS 

could further educate State agencies about the importance of submitting 

complete records. CMS could also consider automated changes within the 

process, such as making more data fields mandatory to complete a 

submission or embedding warnings when submissions are blank in certain 

data fields. Additionally, because some providers terminated “for cause” 

do not have unique NPIs, CMS should consider adding data fields for 

other identifying information, such as SSN, TIN, Employer Identification 

Number (EIN), and DOB, and should make any necessary changes to the 

process to ensure the security of added personally identifiable information. 

CMS’s Process for Sharing Information About Terminated Providers Needs Improvement (OEI-06-12-00031) 14 
 

 

 

AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 

RESPONSE 

CMS concurred with all of our recommendations. 

In response to our recommendation that CMS require each State Medicaid 

agency to report all terminated providers, CMS acknowledged its authority 

under section 1902(a)(41) of the SSA to require State Medicaid agencies 

to report terminations of Medicaid and CHIP providers. Accordingly, it 

will explore options available to implement mandatory State reporting of 

data on “for cause” terminations from Medicaid and CHIP. 

In response to our recommendation that CMS ensure that the process for 

sharing information contains only records that meet the criteria for 

inclusion, CMS stated that it has a new process for sharing information on 

terminated providers, effective November 25, 2013. According to CMS, 

this process—intended for use by staff from CMS, State Medicaid 

agencies, and CHIP—will allow information on terminated providers to be 

shared securely. Under the new process, CMS plans to require States to 

submit a copy of the Medicaid termination letter issued to the provider. 

After submission, CMS intends to review each termination to ensure that it 

meets criteria for inclusion. 

In response to our recommendation to take action to improve the 

completeness of records, especially in data fields critical to identifying 

terminated providers, CMS stated that the new process requires States to 

submit information in critical data fields—such as the field for the NPI— 

as well as a copy of the Medicaid termination letter. We reiterate that 

CMS should consider adding data fields, such as SSN, TIN, EIN and 

DOB, for identifying providers when an NPI is not available. 

We removed a fourth recommendation listed in our draft report—for CMS 

to establish a timeframe for replacing MCSIS—given that CMS has now 

revised the process and moved it to another automated system. 

For the full text of CMS’s comments, see Appendix B. 

CMS’s Process for Sharing Information About Terminated Providers Needs Improvement (OEI-06-12-00031) 15 
 

 

 

 

 

APPENDIX A 

MCSIS Records, as of June 1, 2013 

Table A-1: Number and Percentage of MCSIS Records 

by Year Submitted and Program Submitting 

State Medicaid 

Program 

Submission Year Number of 

Records Percentage 2011 2012 2013* 

AK 0 16 0 16 0.3% 

AL 0 166 24 190 4.0% 

AR 16 67 10 93 2.0% 

AZ 0 0 12 12 0.3% 

CA 0 2,056 18 2,074 44.0% 

CT 5 0 0 5 0.1% 

DE 0 14 0 14 0.3% 

FL 0 9 0 9 0.2% 

GA 0 2 18 20 0.4% 

IA 0 17 4 21 0.4% 

ID 10 3 9 22 0.5% 

IL 0 288 12 300 6.4% 

IN 1 3 0 4 0.1% 

KS 0 2 0 2 <0.1% 

LA 1 0 0 1 <0.1% 

MA 0 2 0 2 <0.1% 

MD 24 67 31 122 2.6% 

ME 0 4 0 4 0.1% 

MI 57 62 27 146 3.1% 

MO 0 12 6 18 0.4% 

MS 0 15 17 32 0.7% 

NE 29 2 12 43 0.9% 

NJ 22 111 26 159 3.4% 

NV 0 18 0 18 0.4% 

NY 443 74 80 597 12.7% 

OH 0 263 0 263 5.6% 

PA 173 187 82 442 9.4% 

RI 0 1 0 1 <0.1% 

TN 0 2 0 2 <0.1% 

VA 3 0 3 6 0.1% 

VT 1 8 5 14 0.3% 

WA 3 13 2 18 0.4% 

WI 0 28 15 43 0.9% 

Medicaid Total 788 3,512 413 4,713 73% 

Medicare Total 0 233 1,493 1,726 27% 

Medicare and 

Medicaid Total 788 3,745 1,906 6,439 100% 

Source: OIG analysis of MCSIS data as of June 1, 2013. 

*Data include submissions from January 1, 2013, to June 1, 2013. 

CMS’s Process for Sharing Information About Terminated Providers Needs Improvement (OEI-06-12-00031) 16 
 

 

 

 

Table A-2: Number and Percentage of MCSIS Records by Termination 

Reason and Program Type 

Termination Reason Listed in 

MCSIS Medicare Medicaid 

Medicare 

and 

Medicaid 

Percentage 

of MCSIS 

Records 

State exclusion/debarment, etc. 0 2,693 2,693 41.8% 

Loss of license or other State action 1,492 601 2,093 32.5% 

Federal exclusion/debarment, etc. 157 962 1,119 17.4% 

Felony conviction 0 188 188 2.9% 

Other 0 106 106 1.6% 

Action taken by Medicare 5 91 96 1.5% 

Deceased provider 71 0 71 1.1% 

Noncompliance 0 37 37 0.6% 

Action taken by Medicaid/CHIP 0 18 18 0.3% 

False or misleading information 1 9 10 0.2% 

Abuse of billing privileges 0 7 7 0.1% 

Misuse of billing number 0 1 1 <0.1% 

Failure to report a change of 

address/ownership 0 0 0 0% 

Onsite review/provider is no longer 

operational 0 0 0 0% 

Total 1,726 4,713 6,439 100% 

Source: CMS MCSIS User Manual and OIG analysis of MCSIS data as of June 1, 2013. 

CMS’s Process for Sharing Information About Terminated Providers Needs Improvement (OEI-06-12-00031) 17 
 

 

 

 

Table A-3: Number and Percentage of MCSIS Records by Program and the 

Termination Reason Listed in MCSIS 

State 

Medicaid 

Program

 State exclusion/debarment, etc. Loss of license or other State action

Federal exclusion/debarment, etc.

 Felony conviction Other Action taken by Medicare Deceased provider  Noncompliance  Action taken by Medicaid/CHIP  False or misleading information  Abuse of billing privileges Misuse of billing number 

AK 1 0 1 4 3 0 0 7 0 0 0 0 

AL 1 30 62 4 1 88 0 0 2 0 2 0 

AR 0 0 1 61 31 0 0 0 0 0 0 0 

AZ 4 8 0 0 0 0 0 0 0 0 0 0 

CA 2,056 0 0 0 18 0 0 0 0 0 0 0 

CT 2 0 0 2 0 0 0 0 1 0 0 0 

DE 14 0 0 0 0 0 0 0 0 0 0 0 

FL 0 1 0 3 0 0 0 3 0 2 0 0 

GA 0 0 1 19 0 0 0 0 0 0 0 0 

IA 3 1 1 16 0 0 0 0 0 0 0 0 

ID 10 0 0 3 0 0 0 4 0 0 5 0 

IL 89 0 211 0 0 0 0 0 0 0 0 0 

IN 0 1 0 0 0 0 0 3 0 0 0 0 

KS 0 0 1 0 0 0 0 1 0 0 0 0 

LA 0 0 0 0 0 0 0 0 0 1 0 0 

MA 0 0 0 0 0 0 0 0 2 0 0 0 

MD 39 39 36 7 0 0 0 0 0 0 0 1 

ME 3 0 0 1 0 0 0 0 0 0 0 0 

MI 2 134 5 0 2 2 0 0 1 0 0 0 

MO 0 4 2 5 1 0 0 0 0 6 0 0 

MS 0 9 0 11 11 1 0 0 0 0 0 0 

NE 27 0 0 0 0 0 0 16 0 0 0 0 

NJ 7 47 83 3 19 0 0 0 0 0 0 0 

NV 4 0 1 0 1 0 0 1 11 0 0 0 

NY 292 148 131 15 9 0 0 2 0 0 0 0 

OH 72 75 116 0 0 0 0 0 0 0 0 0 

PA 55 51 306 26 4 0 0 0 0 0 0 0 

RI 1 0 0 0 0 0 0 0 0 0 0 0 

TN 0 1 0 1 0 0 0 0 0 0 0 0 

VA 0 0 1 5 0 0 0 0 0 0 0 0 

VT 11 0 1 2 0 0 0 0 0 0 0 0 

WA 0 17 0 0 0 0 0 0 1 0 0 0 

WI 0 35 2 0 6 0 0 0 0 0 0 0 

Medicaid 2,693 601 962 188 106 91 0 37 18 9 7 1 

Medicare 0 1,492 157 0 0 5 71 0 0 1 0 0 

Medicare 

and 

Medicaid 

2,693 2,093 1,119 188 106 96 71 37 18 10 7 1 

Source: CMS MCSIS User Manual and OIG analysis of MCSIS data as of June 1, 2013. 

CMS’s Process for Sharing Information About Terminated Providers Needs Improvement (OEI-06-12-00031) 18 
 

 

 

Table A-4: Number and Percentage of MCSIS Records by Provider Type 

and Program Type 

Provider Type Listed in MCSIS Medicare Medicaid 

Medicare 

and 

Medicaid 

Percentage 

of MCSIS 

Records 

Field left blank 0 2,107 2,107 32.7% 

Physician 1,169 789 1,958 30.4% 

Other 355 866 1,221 19.0% 

Nonphysician practitioner (e.g., Nurse 

Practitioner, Physician Assistant, 

Certified Nurse Anesthetist, Certified 

Nurse Midwife, etc.) 

65 307 372 5.8% 

Personal Care Agency/Attendant 0 244 244 3.8% 

Psychologist 95 14 109 1.7% 

Dentist 8 98 106 1.6% 

Pharmacy 0 75 75 1.2% 

Comprehensive Outpatient 

Rehabilitation Facility/Outpatient 

Rehabilitation Facility 

0 53 53 0.8% 

Therapist (Physical Therapist, 

Occupational Therapist, Speech 

Language Pathologist) 

15 33 48 0.7% 

Non-Emergency Transportation 0 46 46 0.7% 

Durable Medical Equipment 0 30 30 0.5% 

Licensed Mental Health Provider 14 16 30 0.5% 

Home Health Agency 0 15 15 0.2% 

Community Mental Health Center 0 5 5 0.1% 

Hospice 0 5 5 0.1% 

Rural Health Clinic 0 3 3 <0.1% 

Ambulatory Surgical Center 3 0 3 <0.1% 

Ambulance 0 2 2 <0.1% 

Independent Diagnostic Testing Facility 2 0 2 <0.1% 

Intermediate Care Facility for Persons 

with Mental Retardation 0 2 2 <0.1% 

Skilled Nursing Facility/Nursing Facility 0 2 2 <0.1% 

Rehabilitation Center (Inpatient) 0 1 1 <0.1% 

Hospital 0 0 0 0% 

Laboratory 0 0 0 0% 

Residential Treatment 

Facility/Psychiatric Residential 

Treatment Facility 

0 0 0 0% 

Federally Qualified Health Center 0 0 0 0% 

Total 1,726 4,713 6,439 100% 

Source: CMS MCSIS User Manual and OIG analysis of MCSIS data as of June 1, 2013. 

CMS’s Process for Sharing Information About Terminated Providers Needs Improvement (OEI-06-12-00031) 19 
 

 

Table A-5: Number and Percentage of MCSIS Records by Provider Type Listed in MCSIS, Program Type, and State 

Medicaid Program State Medicaid Program Field left blank 

PhysicianOther

 Nonphysician Practitioner (e.g., NP, PA, CRNA, Certified Nurse Midwife, etc.)

 Personal Care Agency/Attendant 

Psychologist 

Dentist

 Pharmacy

 Comprehensive Outpatient Rehab Facility/ 

 Outpatient Rehab Facility

 Non-Emergency Transportation

 Therapist (Physical Therapist, Occupational Therapist, Speech Language Pathologist) 

Durable Medical Equipment 

 Licensed Mental Health Provider

Home Health Agency 

 Community Mental Health Center

HospiceRural Health Clinic

Ambulatory Surgery CenterIndependent Diagnostic Testing Facility

AmbulanceIntermediate Care Facility for Persons with

 Mental Retardation Skilled Nursing Facility/Nursing Facility

 Rehabilitation Center (Inpatient) 

AK 0 0 8 3 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 

AL 0 30 148 2 0 0 3 1 0 0 0 4 1 0 0 1 0 0 0 0 0 0 0 

AR 2 2 88 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 

AZ 0 6 3 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 

CA 2,049 13 0 0 0 1 0 2 0 1 6 2 0 0 0 0 0 0 0 0 0 0 0 

CT 0 2 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 

DE 0 10 0 1 0 0 2 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 

FL 0 1 7 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 

GA 7 1 4 2 1 0 0 0 0 0 1 1 1 0 2 0 0 0 0 0 0 0 0 

IA 1 0 2 0 18 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 

ID 8 0 3 2 0 0 0 0 0 5 0 0 0 0 3 0 0 0 0 0 0 0 1 

IL 0 167 32 2 0 1 19 1 53 21 0 0 0 0 0 0 3 0 0 0 1 0 0 

IN 0 0 3 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 

KS 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 

LA 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 

MA 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 

MD 3 64 41 4 2 0 1 0 0 0 0 2 5 0 0 0 0 0 0 0 0 0 0 

ME 0 0 3 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 

MI 2 48 58 5 1 0 3 24 0 0 1 1 0 3 0 0 0 0 0 0 0 0 0 

MO 0 5 1 0 0 2 0 0 0 0 2 1 1 5 0 0 0 0 0 0 1 0 0 

MS 9 9 9 1 0 0 0 0 0 0 0 0 0 0 0 4 0 0 0 0 0 0 0 

NE 0 0 1 1 40 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 

NJ 18 52 48 1 0 2 19 13 0 0 0 1 1 4 0 0 0 0 0 0 0 0 0 

NV 3 2 8 0 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 

NY 0 173 143 164 19 4 31 30 0 5 15 9 3 1 0 0 0 0 0 0 0 0 0 

OH 0 76 3 46 117 0 5 2 0 12 0 1 0 0 0 0 0 0 0 1 0 0 0 

PA 2 92 243 58 26 3 10 1 0 0 4 2 0 0 0 0 0 0 0 1 0 0 0 

RI 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 

TN 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 

VA 1 3 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 

VT 0 0 3 0 9 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 

WA 0 11 3 1 0 0 2 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 

WI 1 18 1 11 0 0 0 0 0 0 2 6 4 0 0 0 0 0 0 0 0 0 0 

Medicaid 2,107 789 866 307 244 14 98 75 53 46 33 30 16 15 5 5 3 0 0 2 2 2 1 

Medicare 0 1,169 355 65 0 95 8 0 0 0 15 0 14 0 0 0 0 3 2 0 0 0 0 

Medicaid 

and 

Medicare 

2,107 1,958 1,221 372 244 109 106 75 53 46 48 30 30 15 5 5 3 3 2 2 2 2 1 

Source: CMS MCSIS User Manual and OIG analysis of MCSIS data as of June 1, 2013. 

CMS’s Process for Sharing Information About Terminated Providers Needs Improvement (OEI-06-12-00031) 20 
APPENDIX 8 

AGENCY COMMENTS 

•..,.....~ 

(,._~ DEPARTMENT OF HEALTII & HUMAN SERVICES Centers for Medicare & Medicaid Services 

Administrator 

Washington, DC 20201 

DATE: 

TO: 

FROM: 

SUBJECT: 

JAN 1 7 Z014 

Daniel R. Levinson 

Inspector General 

Marilyn TaV&lll1er 

Administrutor 

Office oflnspector General (OIG) Draft Report: "CMS System for Sharing 

Information About Terminated Providers Needs Improvement" 

(OEI-06-12-00031) 

The Centers for Medicare & Medicaid Services (CMS) appreciates the opportunity to review and 

comment on the above-referenced OIG draft report. The purpose of this report is to determine 

the extent to which CMS and state Medicaid agencies reported provider information to the 

Medicaid and Children's Health Insurance Program (CHIP) State Information Sharing System 

(MCSIS), to identify MCSIS records not related to providers who were terminated "for cause," 

and to assess the completeness of provider identifying information in the MCSIS records. 

In accordance with section 6401(b)(2) ofthe Affordable Care Act, CMS is committed to 

facilitating state reporting of Medicaid and CHIP "for cause" termination data. CMS phased out 

MCSIS and transitioned to the OnePT portal on November 25, 2013. The new delivery and 

storage process will allow for state-to-state information on terminated providers to be securely 

shared by way ofthe OnePI portal and is intended for use by CMS, state Medicaid, and CHIP 

staff. States will be able to view and download Medicare revocations, previous MCSIS data, and 

state terminations. Medicaid termination letters will also be available for download through the 

new system. 

We appreciate OIG's efforts in working with CMS to ensure that the system for sharing 

information about terminated providers is useful and effective for state Medicaid agencies. Our 

response to each of the OIG recommendations follows. 

OIG Recommendation 

The OIG recommends that CMS, to make complete information available, require each state 

Medicaid agency to report all terminated providers. 

CMS's Process for Sharing Information About Terminated Providers Needs Improvement (OEI-06-12-00031) 21 
 

CMS’s Process for Sharing Information About Terminated Providers Needs Improvement (OEI-06-12-00031) 22 
 

CMS’s Process for Sharing Information About Terminated Providers Needs Improvement (OEI-06-12-00031) 23 
 

 

ACKNOWLEDGMENTS 

This report was prepared under the direction of Kevin K. 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, and 

Maria Balderas served as the lead analyst. Central office staff who 

provided support include Clarence Arnold, Kevin Manley, and 

Christine Moritz. 

We would also like to acknowledge the contributions of other Office of 

Evaluation and Inspections regional office staff, including Nathan Dong. 

CMS’s Process for Sharing Information About Terminated Providers Needs Improvement (OEI-06-12-00031) 24 
 

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.