Department of Health

Medicaid Provider Enrollment

To participate in the Medicaid program, physicians, pharmacists, hospitals and other medical service providers must have a valid license, registration or certification. The Department of Health is responsible for enrolling providers in the Medicaid program and ensuring their credentials are valid. However, we found that, because of weaknesses in the Departmentís controls, providers are able to participate in the Medicaid program even when they lack the required credentials. For example, we determined that 7,680 of the 101,700 fee-based providers (such as physicians and pharmacists) listed as active in the Departmentís files had inactive or expired licenses. When we reviewed a random sample of 100 of these 7,680 providers, we found that 83 of the 100 providers had been without a valid license for at least one year, including 12 who had been without a valid license for at least ten years. We determined that, in the year 2002 alone, at least $950,000 in Medicaid payments had been made to providers lacking valid licenses and at least $1.5 million had been paid for prescriptions written by such providers.

We further determined that some of the providers lacking licenses had been deceased for at least two years. One of these providers had received nearly $124,000 in Medicaid payments since the date of his death in 1995, and another had been recorded as the ordering physician for 659 Medicaid claims totaling more than $104,000 since the date of his death in 1997. We recommended the Department strengthen its controls over the provider enrollment process.

For a complete copy of Report 2003-S-5 click here.