Tuesday, March 17, 2015

GAO Report Looks at State Program Integrity IT Systems

Dianne De La Mare

The General Accounting Office (GAO) has recently released a report, Medicaid Information Technology: CMS Supports Use of Program Integrity Systems but Should Require States to Determine Effectiveness. It evaluates 10 states use of varying types of information technology (IT) systems to support efforts to prevent and detect improper Medicaid payments.

According to the report, all 10 states had implemented a Medicaid Management Information System (MMIS) to process claims and support their program integrity efforts, and 7 had implemented additional types of systems to meet specific needs. Three states were operating MMISs that were implemented more than 20 years ago, but 7 states had upgraded their MMISs, and 2 of those had done so in the past 2 years. In addition, 7 states had implemented other systems, such as data analytics and decision support systems that enabled complex reviews of multiple claims and identification of providers' billing patterns that could be fraudulent.

While the MMISs and other systems implemented by the 10 states were designed primarily for administering Medicaid as a fee-for-service program, in which providers file claims for reimbursement for each service delivered to patients, officials with 7 of the 10 states also administered managed care plans–plans for which provider organizations are reimbursed based on a fixed amount each month–and 1 state administered Medicaid exclusively as managed care.

Officials with the 9 states who administered fee-for-service plans said they used their systems to help conduct pre- and post-payment reviews of claims. All 10 states received technical and financial support from the Centers for Medicare & Medicaid Services (CMS) for implementing the systems. However, the effectiveness of the states' use of the systems for program integrity purposes is not known. CMS does not require states to measure or report quantifiable benefits achieved as a result of using the systems.  Only 3 of the 10 selected states measured benefits.

GAO recommends that CMS require states to measure and report quantifiable benefits of program integrity systems when requesting federal funds, and to reflect their approach for doing so. To obtain a copy of the complete report go to http://www.gao.gov/products/GAO-15-207.

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