Colorado Did Not Always Identify or Prevent Excluded Providers from Participating in the Medicaid Program.

摘要

Pursuant to Title XIX of the Social Security Act (the Act), the Medicaid program provides medical assistance to low-income individuals and individuals with disabilities. The Federal and State Governments jointly fund and administer the Medicaid program. At the Federal level, the Centers for Medicare & Medicaid Services (CMS) administers the program. Each State administers its Medicaid program in accordance with a CMS-approved State plan. Although the State has considerable flexibility in designing and operating its Medicaid program, it must comply with applicable Federal requirements. CMS reimburses State Medicaid agencies based on the Federal medical assistance percentage for claimed Medicaid expenditures, including Medicaid expenditures for items and services furnished, ordered, or prescribed by providers enrolled in the States Medicaid program. The U.S. Department of Health and Human Services, Office of Inspector General (OIG), under Congressional mandate, established a program to exclude individuals and entities affected by various legal authorities contained in sections 1128 and 1128A of the Act. The effect of an exclusion (not being able to participate) is that no payment will be made by the Medicaid program for any items and services furnished, ordered, or prescribed by an excluded individual or entity. This payment prohibition applies to the excluded person, anyone who employs or contracts with the excluded person, and any hospital or other provider where the excluded person provides services. The exclusion applies regardless of who submits the claims and applies to all administrative and management services furnished by the excluded person. There is a limited exception to exclusions for the provision of certain emergency items or services not provided in a hospital emergency room.