Medicaid Provider Enrollment Process: Stuck in a Snowbank?’s cold out there for health care providers! Expect a more stringent re-certification process going forward! DHHS was cited for being lax on provider enrollment or stuck in a metaphoric snowbank. I, on the other hand, got stuck in an actual snowbank.

Over President’s Day weekend, my mom, sister, daughter, niece, and nephew all drove to the Omni Homestead in Hot Springs, VA for a few days of skiing and snow tubing. Fun, right? It was a wonderful time, but getting there was an absolute fiasco that we will laugh about for years to come. Now, however, it’s too soon.

Friday the 12th, I almost successfully drove over a snowy, icy hill, known as Airport Rd. Then, this happened…

Caught in a snowbank.

The catastrophic first day (the 12th), as bad as it was, the tomfoolery gave me the inspiration for this blog. On the way to The Homestead, I got my car stuck in a snowbank with my daughter for hours waiting for a tow truck, who had a really hard time finding us. I drive a two-wheel drive, sedan. My sister, on the other hand, enjoyed her youngest daughter (my niece) throwing up from car sickness the entire 5-hour drive. On the bright side, my daughter was excited to sit in the back of a police officer’s car. She even held up the handcuffs as a pose.

As I sat in my Dodge Dart with my 15-year-old girl for hours, I had 3 dentists call me regarding small, alleged overpayments. The tiniest amount at issue was $34k. The largest was just $56k. One dentist was undergoing a RAC audit. Another was undergoing a CERT audit. The third dentist was undergoing a “meaningful use” audit. My 5-hour drive quickly became 8.

The next call informed me that DHHS was being scrutinized for allowing providers maintain a Medicaid contract, who, purportedly, were not qualified. Considering I have had multiple provider-clients lately accused of not being qualified when they were qualified. My interest was perked. As I sat stuck in a snowbank, was DHHS’ provider enrollment process stuck in a similar snowbank and unable to move?

The NC State Auditor released the February 2021 Performance Audit, “Medicaid Provider Enrollment.”


The Medicaid Provider Enrollment process did not ensure that only qualified providers were approved to provide services to Medicaid beneficiaries and to receive payments from North Carolina’s Medicaid program. Specifically, the Division:

  • Did not identify and remove enrolled providers from the Medicaid program who had their professional license suspended or terminated.
  • Allowed all providers who had professional license limitations to remain enrolled in the Medicaid program.
  • Did not ensure that its contractor verified all professional credentials during the Medicaid provider enrollment re-verification process.
  • Did not require its contractor to verify provider ownership information during the Medicaid provider enrollment re-verification process.

As a result, there was an increased risk that providers whose actions posed a threat to patient safety were enrolled in Medicaid and could receive millions of dollars in improper payments from the State.

According to the Performance Audit, the following are three, specific examples of providers allowed to continue to participate in the Medicaid program:

  1. A physician had a license limitation that prohibited treating any female patients. A previous license limitation had required that a chaperone be present and document their presence any time the physician examined a female patient because of multiple past sexual and professional misconduct allegations. Despite the license limitation restricting the physician from treating female patients, the physician billed Medicaid for services provided to 208 female patients in the amount of $78,000 from October 18, 2018, through June 30, 2020.
  2. A physician was placed on probation for multiple “departure[s] from the standards of acceptable and prevailing medical practice.” The physician used a single-use syringe on multiple patients, injected unused pharmaceutical product from a previously used syringe into more than one patient, and failed to properly dispose of human waste – instead, the physician stored it “in a box in a closet near the nurse’s station.”
  3. A physician had a license limitation that prohibited treating any female patients. The medical board was “concerned about the process [the physician] follows for breast examinations” and found the physician’s conduct to be “a departure from the standards of acceptable and prevailing medical practice within the meaning of NCGS §90-14(a)(6).” Despite not receiving payments from Medicaid, the provider remained active in the Medicaid claims processing system (NCTracks) and was eligible to receive payments.

While I will be the first to admit that these examples are egregious, I can vouch that there are also providers accused of not being qualified when they are truly qualified. False accusation of not being qualified is also a problem. However, in light of this Performance Audit, DHHS will surely be more strict in future re-credentialing. There may be a blizzard of Medicaid provider terminations.

DHHS’ excuse when confronted with the accusation of sloppy provider enrollment process was, “The Division said that it did not have the authority to remove providers with current license limitations from the Medicaid program.” I call bullshxx and yellow snow.

DHHS routinely argues in court that it has the authority to terminate Medicaid providers’ contracts without cause. Now, I disagree, but that has been DHHS’ stance. For DHHS to claim it does not have the authority to terminate providers’ Medicaid contracts is disingenuous.

CMS was involved in this Performance Audit and instructed DHHS that it does have the authority to terminate providers who do not qualify for Medicaid participation.

Numerous home health agencies and adult care facilities were found to have staff who were not qualified. It appears that the State Auditor’s argument is that, if an agency has unqualified staff, then 100% recoupments are in order. We will have to wait and see whether DHHS attempts recoupments or terminations, as it is instructed.

Meanwhile, my daughter and I were towed out of the snowbank.

Back of the police car!

About kemanuel

Medicare and Medicaid Regulatory Compliance Litigator

Posted on February 19, 2021, in Medicaid. Bookmark the permalink. Leave a comment.

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