News: CMS launches initiatives to cut down fraud and waste in Medicaid

Last week, CMS announced new initiatives to improve Medicaid program integrity “through greater transparency and accountability, strengthened data, and innovative and robust analytic tools,” according to the CMS release.

Going forward, CMS will use the following initiatives to increase the integrity and accountability of the Medicaid program:

• Emphasize program integrity in audits of state claims for federal match funds and medical loss ratios: CMS will begin auditing some states based on the amount spent on clinical services and quality improvement versus administration and profit, according to the release, including reviews of states’ rate settings. The audits, in general, will address issues identified by the Government Accountability Office and the Office of Inspector General (OIG).
• Conduct new audits of state beneficiary eligibility determinations: CMS will audit states that have been previously found to be high risk by the OIG to examine how they determine which groups are eligible for Medicaid benefits.
• Optimize state-provided claims and provider data: CMS will use advanced analytics and other solutions to improve Medicaid eligibility and payment data and maximize the potential program integrity purposes.

These new initiatives, according to CMS Administrator Seema Verma, “are the vital steps necessary to respond to Medicaid’s evolving landscape and fulfill our responsibility to beneficiaries and taxpayers.”

Editor’s note: To read the full CMS release, click here. To learn how to use OIG findings to shape your CDI program’s focus, click here.