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CMS Failed to Report Providers' Adverse Actions, Says OIG

 |  By cclark@healthleadersmedia.com  
   September 23, 2010

The Centers for Medicare & Medicaid Services took adverse actions against hundreds of healthcare providers, but did not report them to the Healthcare Integrity and Protection Databank as required because the agency did not regard the providers' activities as fraud or abuse.

That's according to a report from the Office of Inspector General this week which recommends that CMS promptly start reporting such events. "Users (of this databank) pay fees for each query they submit to the HIPDB with the expectation that they will receive complete and accurate information in return," the OIG report states.

The HIPDB, which as of 18 months ago contained reports of 389,273 adverse actions, "may be used for employment, affiliation, certification or licensure decisions," the OIG said. Just 5,146 adverse actions of of the 389,273 had been reported by CMS.

The information helps providers select entities who are in good standing with legal healthcare requirements and conditions of participation in Medicare and Medicaid programs.

"The CMS should report all adverse events as required," the investigation summary concludes.

The OIG says CMS neglected to report all of the 148 actions taken against laboratories in 2007 or all of the adverse actions taken against durable medical equipment suppliers in 2008. It did not report any adverse actions taken against 45 nursing homes, which were terminated from participating in the Medicare program from 2004 to 2008, until 2009, "well after the required reporting timeframe."

CMS imposed civil monetary penalties and terminations against managed care and prescription drug plans that fail to comply with Medicare requirements, but failed to report 30 adverse actions it took against those entities between Jan. 1, 2006 to July 31, 2009.

Such adverse events that should have been reported include:

  • Any loss, revocation or suspension of a license or certification agreement or contract for participation in a federal or state healthcare program
  • Any loss of the right to apply for or renew a license, certification or agreement or contract.
  • Any reprimand, censure or probation
  • Any other negative action or finding by a federal or state agency that is publicly available, including limitations on scope of practice, liquidations, injunctions, exclusions, revocations, suspensions or forfeitures.
  • The conviction or fining of a mental health institution for condoning physically abusive methods of controlling patients.
  • The conviction or fining of a chiropractor and a medical supply company for providing kickbacks in exchange for patient referrals
  • The deferred conviction of a practitioner for accepting money for referrals to a specialist and sentencing of the practitioner for a 2-year probationary period.
  • A civil judgmeent against a physician for medical malpractice resulting in an award to the plaintiff
  • A deferred conviction of a practitioner for possession and abuse of drugs and sending the practitioner to a rehabilitation facility.

  • Any civil judgment, including those against a clinical laboratory for fraudulent billing and misleading marketing, against a nursing home for neglect of and failure to clean patient rooms, against a plastic surgeon for misrepresenting claims as noncosmetic procedures in order to receive payment.

The OIG recommended that CMS "should educate staff and contractors about the types of adverse actions to be reported and the timeframes for reporting."

Under provisions of the Patient Protection and Affordable Care Act, the National Practitioner Data Base, which collects information related to the professional competence and conduct of physicians, dentists and other healthcare practitioners, will absorb data from the HIPDB.

 

 

 

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