Medicare Program Integrity: CMS Continues Efforts to Strengthen the Screening of Providers and Suppliers

"Why GAO Did This StudyAccording to the Centers for Medicare & Medicaid Services (CMS)-the agency within the Department of Health and Human Services (HHS) that administers the Medicare program-more than 1.5 million health providers and suppliers of medical equipment were enrolled in the Medicare program in 2011, and 30,000 more enroll each month. CMS has established Medicare enrollment standards and procedures intended to ensure that only qualified providers and suppliers can enroll. While most providers and suppliers pose a limited risk to the Medicare program, our previous work found persistent weaknesses in CMS's Medicare enrollment standards and procedures that increased the risk of enrolling entities intent on defrauding the program. In 2010, the Patient Protection and Affordable Care Act (PPACA) authorized CMS to implement procedures to strengthen the Medicare enrollment process.GAO was asked to review CMS's Medicare provider enrollment procedures. In this report, GAO describes (1) how CMS and its contractors use provider and supplier enrollment information to prevent improper payments and factors that may affect the usefulness of this information, and (2) the extent to which CMS has implemented new provider and supplier enrollment screening procedures since the enactment of PPACA. To do so, GAO reviewed relevant regulations and documents, and interviewed officials from CMS"

According to the Centers for Medicare & Medicaid Services (CMS) -- the agency within the Dept. of Health and Human Services (HHS) that administers the Medicare program -- more than 1.5 million health providers and suppliers of medical equipment were enrolled in the Medicare program in 2011, and 30,000 more enroll each month. CMS has established Medicare enrollment standards and procedures intended to ensure that only qualified providers and suppliers can enroll. While most providers and suppliers pose a limited risk to the Medicare program, GAO found persistent weaknesses in CMS's Medicare enrollment standards and procedures that increased the risk of enrolling entities intent on defrauding the program. In 2010, the Patient Protection and Affordable Care Act (PPACA) authorized CMS to implement procedures to strengthen the Medicare enrollment process. This report describes (1) how CMS and its contractors use provider and supplier enrollment information to prevent improper payments and factors that may affect the usefulness of this information; and (2) the extent to which CMS has implemented new provider and supplier enrollment screening procedures since the enactment of PPACA.Tables and figures. This is a print on demand report.