Sneak Preview: CMS To Conduct Medicaid Audits To Boost Integrity

July 25, 2018 | By Jerry Ashworth | Post a Comment

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xsass_bookshot(The following was excerpted from a recent article in the Single Audit Information Service.) To ensure that states are establishing appropriate reimbursement rates and claiming accurate federal matching funds under the Medicaid program, the Department of Health and Human Services (HHS) Centers for Medicare and Medicaid Services (CMS) will begin targeted audits of some states’ managed care organization (MCO) financial reporting. These audits are among several new steps the agency plans to take as part of its overall Medicaid program integrity strategy to reduce improper payments.

CMS recently issued a fact sheet discussing new or enhanced Medicaid program integrity initiatives, along with some of its existing program oversight initiatives. CMS notes that total Medicaid spending increased from $456 billion in 2013 to an estimated $576 billion in 2016, with the federal share increasing from $263 billion to an estimated $363 billion during this period. “With this historic growth comes an equally growing and urgent responsibility to ensure sound stewardship and oversight of our program resources,” CMS said. “As part of CMS’ plan to reform Medicaid using the three pillars of flexibility, accountability and integrity, we are announcing a new strategy to ensure we are keeping the Medicaid program sustainable for our future.”

CMS explained that under the targeted MCO audits, it would assess actual claims to determine if they match what MCOs have reported. In addition, CMS said it would review high-risk findings in recent Government Accountability Office (GAO) and HHS Office of Inspector General (OIG) reports related to the Medicaid program. For example, while CMS has expanded the use of federal-state collaborative audits of MCOs and providers under contract to MCOs, and required states to report overpayments they have identified and recouped along with state expenditures on a quarterly basis, a GAO report released earlier this year determined that these oversight efforts do not ensure the identification and reporting of overpayments to providers and unallowable costs by MCOs.

CMS further plans to conduct new audits of state beneficiary eligibility determinations in states previously reviewed by the HHS OIG. It also seeks to strengthen its efforts to provide effective Medicaid provider education to reduce incorrect billing. In addition, now that all 50 states, the District of Columbia and Puerto Rico are submitting program data to the Transformed Medicaid Statistical Information System (TMSIS), CMS explained that it will validate the quality and completeness of the data over the next several months, as well as use “advanced analytics and other innovative solutions to both improve TMSIS data and maximize the potential for program integrity purposes.”

Other new or enhanced initiatives that CMS plans to take to improve Medicaid integrity include:

  • share knowledge about data assessment with states to enable them to conduct data analytics pilots on Medicaid claims to identify potential areas to target for investigation;
  • launch a pilot process to screen Medicaid providers on behalf of states to improve efficiency and coordination across Medicaid and Medicare, and reduce state and provider burden;
  • share data, such as information in the Social Security Administration’s Death Master File, with states to support provider enrollment activities in both the Medicaid and Medicare programs; and
  • report state Medicaid performance measures on a publicly available Medicaid scorecard.

(The full version of this story has now been made available to all for a limited time on Thompson’s Grants Compliance Expert site.)

As a reminder, the following is our final Federal Funding Training Forum scheduled for 2018. Please let me know if you have questions or can make this forum. We hope to see you there!

  • Wednesday October 17 – Friday October 19 in ATLANTA


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