2012 Session

Budget Amendments - HB30 (Committee Approved)

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Medicaid Provider Exclusion and Removal (language only)

Item 310 #1h

Item 310 #1h

Health And Human Resources
Medical Assistance Services, Department of

Page 240, after line 53, insert:
"I.  It is the intent of the General Assembly that the Department of Medical Assistance Services exercise the full extent of federal flexibility in excluding and removing providers as needed to ensure Medicaid program integrity in compliance with federal and state statutes.  The department shall develop a plan to implement programmatic changes to obtain accurate and timely provider information from licensure agencies, to require criminal background checks, to develop a valid risk assessment instrument that can be used to measure patient risk and withstand provider appeals, to verify the physical presence of providers, and to determine how additional provider information required by health care reform can be used to strengthen program integrity activities, among others.   The department shall report on the plan to the House Appropriations and Senate Finance Committees by December 1, 2012."

(This amendment adds language which would require the Department of Medical Assistance Services (DMAS) to fully utilize the authority granted by the federal government to exclude or remove providers from its network in certain instances. A recent report of the Joint Legislative Audit and Review Commission found that DMAS is not fully utilizing the authority granted by the federal government to exclude or remove providers from its network. Federal and state law set forth criteria for the exclusion and removal of Medicaid providers from the fee-for-service network. Federal law requires certain exclusions, and allows states to use others. For example, mandatory federal criteria to exclude and remove providers from its fee-for-service network include: (i) the commitment of Medicaid or Medicare fraud, (ii) a conviction of patient abuse or other offenses that pose a risk to Medicaid patients, or (iii) exclusion by the federal government. In addition, the Code of Virginia excludes providers who have been convicted of a felony or who do not meet certification, licensure, or education requirements of Virginia licensing boards. With the implementation of federal health care reform, states will be required to collect more information during the provider enrollment process; however, the law does not address whether states should act on the information. Currently, few providers are excluded or removed from providing Medicaid services by DMAS, and those that are removed are almost exclusively due to felonies or lack of licensure. Attempts to exclude based on risk to patients have generally not withstood provider appeal. Further, DMAS does not verify the physical presence of new providers to ensure that they are valid providers, which has been found to be the cause of fraudulent activity in other states. DMAS relies on accuracy and timeliness of information from licensing and federal agencies, and does not conduct criminal background checks to ensure that prior history does not suggest potential risk to patients.)