Wednesday, May 3, 2017

GAO Report Recommendations to Improve Medicaid Program Integrity Activities

Dianne De La Mare


The US Government Accountability Office (GAO) has released a new report, Medicaid Program Integrity: CMS Should Build on Current Oversight Efforts by Further Enhancing Collaboration with States, that provides suggestions for how the Centers for Medicare & Medicaid Services (CMS) could better support states’ Medicaid activities. 

Medicaid is a significant and growing component of federal and state budgets. It is the second largest health insurance program after Medicare as measured by expenditures, and is estimated to account for the second largest share of total state spending. Medicaid also is undergoing a period of transformative change, as enrollment under the Affordable Care Act (ACA) and program spending is projected to increase 66 percent to over $950 billion by FY 2025. 

In this report, GAO examines CMS’ oversight and support of states’ Medicaid program integrity efforts by looking at 4 areas:
1) how CMS tailors its reviews of states’ Medicaid program integrity activities to account for differences in states’ health care delivery systems and program integrity needs;
2) states’ experiences with collaborative audits; 
3) how the Medicaid Integrity Institute supports states’ efforts to address program integrity vulnerabilities; and 
4) the steps CMS has taken to share promising program integrity practices. 

The GAO reviewed CMS documents (including state program integrity reports and data on collaborative audits) and interviewed CMS and eight other state officials to make its conclusions and recommendations. The report states that CMS has taken a number of important steps to improve its oversight and support of states’ Medicaid program integrity efforts including its: 
1) use of focused reviews to address managed care plan oversight and other high risk areas; and 
2) shift to collaborative audits to help identify a substantial amount of potential overpayments.

Some states’ negative experiences with or reluctance to seek collaborative audits, however, highlight potential areas of improvement as CMS transitions Medicaid audits to the new Unified Program Integrity Contractors (UPICs). Further, both CMS and the states have a role in identifying promising program integrity practices that can be shared in order to help improve oversight in the Medicaid program. The GAO recommends that CMS identify opportunities to address barriers that limit states’ participation in collaborative audits, and, in collaboration with states, take additional steps to collect and share promising program integrity practices. The US Department of Health and Human Services concurs with GAO’s recommendations.

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