Tuesday, June 24, 2014


Dianne De La Mare

In a recent report from the US Government Accountability Office (GAO), Medicaid Program Integrity: Increased Oversight Needed to Ensure Integrity of Growing Managed Care Expenditures, the agency concludes that the Centers for Medicare & Medicaid Services (CMS) is failing to ensure proper oversight of Medicaid Managed Care Organizations (MCOs). 

Medicaid Managed Care is growing at a faster rate than payments under the traditional fee-for-service (FFS); and yet, in the seven states GAO reviewed, five state Program Integrity (PI) units and four Medicaid Fraud Control Units (MFCUs) indicated that they primarily focus their PI efforts on Medicaid FFS claims and have not begun to closely examine PI in Medicaid MCOs. In addition, the report finds that federal entities have taken few steps to address Medicaid MCO PI. Specifically, CMS has largely delegated managed care PI oversight activities to the states, without updating any CMS PI guidance. 

Further, CMS does not require states to audit Medicaid MCO payments, and state officials told GAO during this study that they need additional CMS guidance in this area and the option to obtain audit assistance from existing Medicaid PI contractors in overseeing Medicaid MCO PI. The report recommends that CMS increase its oversight of PI efforts by requiring states to audit payments to and by Medicaid MCOs; update its guidance on Medicaid MCO PI; and provide states additional support for Medicaid MCO oversight. 

To obtain a complete copy of the GAO report go to http://www.gao.gov/products/GAO-14-341.

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