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CMS Outlines New Medicaid Program Integrity Activities

The federal government will introduce a number of initiatives to combat Medicaid waste, fraud, and abuse in the coming months.

In an article on the Centers for Medicare & Medicaid Services’ blog, CMS administrator Seema Verma outlined her agency’s major Medicaid program integrity efforts of the past year, including:

  • Oversight of state Medicaid claiming and program integrity
  • Disallowing unallowable claims of federal funding
  • Increased audits and oversight
  • Data sharing and partnerships
  • Education, technical assistance, and collaboration
  • Reducing improper payments

Initiatives to be introduced in the coming months include (as described in the blog post):

  • A proposed comprehensive update to Medicaid’s fiscal accountability regulations, to increase states’ accountability for supplemental payments. The update includes additional state reporting, clearer financial definitions, and stronger federal guidance to ensure that states use supplemental payments properly.
  • A proposed regulation to further strengthen the integrity of the Medicaid eligibility determination process, including enhanced requirements around verification, monitoring changes in beneficiary circumstances, and eligibility redetermination.
  • Additional guidance on the Medicaid Managed Care Final Rule from 2016 to further state implementation and compliance with program integrity safeguards, such as reporting overpayments and possible fraud.
  • Release of improvements to the Medicaid and CHIP Scorecard—a dashboard of program measures that increases public transparency about the programs’ administration and outcomes. The improvements include two program integrity measures to enhance transparency and continue to provide states with performance measures related to their Medicaid programs. Examples of such program integrity measures may include measures based on state initiation of collaborative investigations with their UPIC, state participation in the HFPP at any level, and performance data derived from improper payment drivers.
  • Conduct provider screening on behalf of states for Medicaid-only providers to improve efficiency and coordination across Medicare and Medicaid, reduce state and provider burden, and address one of the biggest sources of error as measured by PERM.
  • Medicaid provider education through Targeted Probe and Educate—which identifies providers who have high error rates and educates them on billing requirements—to reduce aberrant billing, as well as education provided through Comparative Billing Reports—which show providers their billing patterns compared to their peers.
  • Audit state claiming of federal matching dollars to address areas that have been identified as high-risk by GAO and OIG, as well as other behavior previously found detrimental to the Medicaid program.

Learn more in the CMS blog article “Medicaid Program Integrity: A Shared and Urgent Responsibility.”

MACPAC Meets

The Medicaid and CHIP Payment and Access Commission met for two days last week in Washington, D.C.

The following is MACPAC’s own summary of the sessions.

The Commission wrapped up its work on the June 2019 Report to Congress on Medicaid and CHIP at the April meeting, with sessions reviewing four of the report’s five draft chapters on Thursday morning, and votes on potential recommendations later in the afternoon.

First on Thursday’s agenda was a draft June chapter on Medicaid prescription drug policy, which contained draft recommendations to provide states with a grace period to determine Medicaid drug coverage and raise the cap on rebates. The Commission then revisited hospital payment policy, with a draft chapter and recommendation on how to treat third-party payment in the definition of Medicaid shortfall when determining disproportionate share hospital payments. Next, commissioners considered two recommendations proposed as part of a June chapter on improving the effectiveness of Medicaid program integrity. The final morning session addressed the Commission’s proposed recommendation on therapeutic foster care.

The Commission returned from lunch for two presentations discussing preliminary findings of forthcoming congressionally mandated reports. The first afternoon session presented initial findings from a MACPAC review of state Medicaid utilization management policies related to medication-assisted treatment, to be issued in October. The session immediately following presented preliminary findings for a January 2020 study on Medicaid standards for institutions for mental diseases. Both reports are required as part of the SUPPORT for Patients and Communities Act (P.L. 115-271). Votes on June 2019 recommendations closed out the day.

Friday’s sessions opened with a review of the fifth draft chapter slated for June, on Medicaid in Puerto Rico. The second session of the morning reviewed a proposed rule issued by the Centers for Medicare & Medicaid Services in March to promote interoperability in federal health care programs. The April meeting closed with a review of evaluations of integrated care for dually eligible beneficiaries.

Supporting the discussion were the following presentations:

  1. Review of Draft Chapter for June Report and Recommendations on Prescription Drug Policy: Grace Period and Cap on Rebates
  2. Review of Draft Chapter for June Report and Proposed Medicaid Shortfall Recommendation
  3. Review of Draft Chapter on Improving the Effectiveness of Medicaid Program Integrity and Recommendations
  4. Review of Recommendation for June Report Chapter on Therapeutic Foster Care
  5. Preliminary Findings from Congressionally Mandated Study on Medication-Assisted Treatment Utilization Management Policies
  6. Preliminary Findings on Congressionally Mandated Study on Institutions for Mental Diseases
  7. Review of Draft June Report Chapter on Medicaid in Puerto Rico
  8. Review of Proposed Rule to Promote Interoperability in Federal Health Care Programs
  9. Evaluating Integrated Care: Review of Results from Literature

Because NASH members and private safety-net hospitals serve so many Medicaid patients, MACPAC’s deliberations are especially relevant to them because its recommendations often find their way into future Medicaid and CHIP policies.

MACPAC is a non-partisan legislative branch agency that provides policy and data analysis and makes recommendations to Congress, the Secretary of the U.S. Department  of Health and Human Services, and the states on a wide variety of issues affecting Medicaid and the State Children’s Health Insurance Program.  Find its web site here.

 

Verma Speaks at Medicaid Managed Care Summit

Centers for Medicare & Medicaid Services administrator Seema Verma recently addressed the Medicaid Managed Care Summit, which was held in Washington, D.C.

Ms. Verma’s speech focused on four major areas:

  • Empowering states to function as laboratories for innovation by giving them the flexibility to introduce changes that work best for their own citizens.
  • Developing Medicaid and CHIP scorecards that present data on health outcomes, quality metrics, and CMS’s administrative performance.
  • Improving Medicaid program integrity, including through “…targeted audits to ensure that provider claims for actual health care spending match what the [Medicaid managed care] health plans are reporting financially.”
  • Strengthening CMS’s use of data in Medicaid oversight.

See Ms. Verma’s complete remarks here.