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What Can Medicaid Plans and Providers Expect as a Result of New CMS Medicaid Integrity Initiatives?


What Can Medicaid Plans and Providers Expect as a Result of New CMS Medicaid Integrity Initiatives?

On June 26, 2018, the Centers for Medicare and Medicaid Services (CMS) announced several initiatives to strengthen Medicaid integrity. While these initiatives are directed to State Medicaid Agencies, Medicaid managed care organizations and providers should expect a trickledown effect that could impact their operations and finances.

As described by CMS, the new initiatives are:

  • CMS will begin targeted audits of some states’ managed care organization (MCO) financial reporting. The audits will include review of high-risk vulnerabilities identified by the Government Accountability Office (GAO) and Office of the Inspector General (OIG) as well as other behavior previously found detrimental to the Medicaid program.
  • CMS will conduct audits of state beneficiary eligibility determinations in states previously reviewed by OIG.
  • CMS will validate the quality and completeness of data submitted to it by states. CMS’ ongoing goal is to use advanced analytics and other innovative solutions to maximize the data’s potential for program integrity purposes. CMS will also conduct data analytics pilots which will help states apply algorithms and insights to analyze Medicaid state claim data and identify potential areas to target for investigation.
  • CMS will pilot a process to screen Medicaid providers on behalf of states, on an opt-in basis.
  • CMS will enhance Data Sharing and Collaboration with states. For example, CMS is making the Social Security Administration’s Death Master File available for states to support provider enrollment activities.
  • CMS will publicly report state performance on the Medicaid scorecard. Future versions of the scorecard will include state program integrity performance measures.
  • CMS will provide Medicaid provider education to reduce improper payments.

As CMS puts additional pressure on states in these areas, it is reasonable to expect that states will put additional pressure on their managed care organizations and providers to be accurate, truthful, and compliant with Medicaid requirements. Medicaid managed care plans and providers should review their compliance plans in preparation for increased scrutiny from their state Medicaid Agency. The most effective review will focus on the hot button items previously identified by the GAO and OIG, but not stop there. It is clear from CMS’ announcement that it views these initiatives as a way to prevent continuation of the upward federal Medicaid expenditure that occurred between 2013-2016—from $263 billion to an estimated $363 billion. Clawbacks from Medicaid managed care plans and providers may ultimately become the government’s strategy to curtail what it characterizes as a burden on taxpayers and the fiscal sustainability of the Medicaid program.

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