CMS Directs Minnesota to Impose Medicaid Provider Enrollment Moratoria Amid Fraud Concerns
The Centers for Medicare & Medicaid Services (CMS) has directed the State of Minnesota to temporarily limit Medicaid provider enrollment across multiple service categories, citing concerns over potential fraud and unusually rapid growth in provider participation and payments. The order is accompanied by a larger conflict between Minnesota and the United States Department of Health and Human Services (HHS) that has taken action to withhold over 2 billion dollars of federal Medicaid funds to the state.
Background of the Dispute
The Minnesota Department of Human Services is currently challenging the decision of HHS to withhold federal Medicaid funds. CMS stated, “CMS analysis of Minnesota Medicaid data shows extraordinary growth in provider enrollment and payments for several of these services that is inconsistent with beneficiary growth and service utilization trends.” The federal officials made a conclusion that Minnesota had not done enough to curb the risk of fraud in its Medicaid program.
Provider Enrollment Moratoria
CMS has responded by asking Minnesota to temporarily limit new Medicaid enrollments in 13 categories of providers that CMS considers to be high-risk. These include:
- Adult companion services,
- Adult day services,
- Adult rehabilitative mental health services,
- Assertive community treatment,
- Community first services and supports,
- Early intensive developmental and behavioral intervention,
- Individualized home supports,
- Integrated community supports,
- Intensive residential treatment services,
- Night supervision services,
- Nonemergency medical transportation services,
- Peer recovery support services, and
- Recuperative care.
The state had already declared a freeze of two years on the licensing of some of the home- and community-based services and adult day programs.
Federal Government and Regulatory Structure
The Medicaid provider enrollment moratoria authority was introduced as a program integrity addition in 2010 through the Affordable Care Act. It is based on these provisions, defined in the Social Security Act, Section 1902(kk)(4)(B), and the Code of Federal Rules, Part 455, that CMS can direct states to place temporary enrollment limits whereby some types of providers are found to be high-risk providers of fraud.
Under federal regulations, CMS must consult with the State Medicaid Agency before a moratorium is imposed. Although SMA might choose not to take action on a moratorium on the grounds that this would greatly impact beneficiary access. The initial term of a moratorium is six months and may be extended thereafter by the SMA in six-month increments.
Implications for Providers
There should be higher compliance and administrative demands on the providers working within the affected categories. Recertification of current enrollments will likely increase, and it may cause delays and increased paperwork. Also, organizations might struggle to recruit new professionals if the enrollment requirements reduce the number of Medicaid provider-approved professionals.
