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CMS In Hot Water For Inability To Stop Medicaid And Medicare Abuse

At Allegiant Experts, we wholeheartedly believe that we side with what’s right. It is right that Americans have access to much needed healthcare, especially when they endure unexpected, dire situations. It is also right that Americans are treated by experienced and knowledgeable physicians who have dedications towards providing better health and safety to their communities at large.

This is why it is with great disappointment that we recently learned of the Centers for Medicare & Medicaid Services’ inability to implement adequate background checks on nurses, doctors and other clinicians to ensure that they each have licenses and have no criminal records. As reported by Shannon Muchmore on, CMS was recently severely reprimanded for failing to reduce fraud and abuse of Medicaid and Medicare.

According to a study conducted in June of last year by the Office of Inspector General, 37 states have not implemented fingerprint-based criminal background checks on Medicaid and Medicare providers. The OIG study also found that “11 States reported that they have not implemented site visits (and) 14 States reported that they would not finish revalidating existing high- and moderate risk providers by the September 2016 deadline.”

Muchmore notes that lawmakers have seemingly had enough of CMS’ negligence. She writes that, just last week, New York-based member of the U.S. House of Representatives, Chris Collins “lambasted” the agency’s performance and stated that it would no longer be tolerated in the private sector. He was particularly harsh towards Dr. Shantanu Agrawal, who is the deputy administrator and director of the CMS’ Center for Program Integrity.

“If you worked for me, you’d be fired this afternoon,” Collins admonished. So just how bad is the abuse of Medicaid and Medicare? Muchmore reveals that recent OIG reports have found that, in 2014, nearly $80 billion were misspent on Medicare and Medicaid. On the OIG website, it is explained why proper background checks on healthcare providers can help curb the unnecessary losses.

“To bill for items and services provided to beneficiaries, providers must enroll, and periodically revalidate this enrollment, in Medicaid,” they report, “Effective provider enrollment screening is an important tool in preventing Medicaid fraud. To protect Medicaid against ineligible and fraudulent providers, the Affordable Care Act requires States to screen Medicaid providers according to their risk for fraud, waste, and abuse using enhanced screening procedures.”

Unfortunately, Medicare’s Provider Enrollment, Chain and Ownership System has a long history of being “incomplete, inconsistent and inadequate.” So says Ann Maxwell, who is the assistant inspector general with the OIG’s Office of Evaluation and Inspections, reports Muchmore. “A recent review found that nearly all provider names from PECOS did not match the names filed with state Medicaid agencies,” she writes.

Dr. Agrawal, however, makes the claim that questionable payments come as a result of mistakenly incomplete documentation from providers. He insists that the CMS has to depend on states for verifying Medicaid information and that they are working with states to provide technical assistance. “It’s not a single solution, it’s a multitude of solutions,” he is quoted as saying.

The Allegiant Experts team would have to agree with him on that. After all, fraud is complex and criminals are brilliant! For information on how our clinical experts can help your legal battle to put a stop to criminals who abuse our healthcare system, please don’t hesitate to contact us at 407-217-5831.

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