Excluded Providers in Medicaid Managed Care Entities

摘要

The Office of Inspector General (OIG) is authorized to exclude certain individuals and entities (providers) from participating in federally funded health care programs. These programs, such as Medicaid managed care, are prohibited from paying for any items or services furnished, ordered, or prescribed by an excluded provider or paying anyone who contracts with an excluded provider. Nationally, approximately 70 percent of Medicaid recipients receive some or all of their Medicaid services through managed care. However, little was known about how Medicaid managed care entities (MCE) prevent excluded providers from entering their provider networks, or how successful MCEs are in preventing excluded providers from entering their provider networks.