Kusserow on Compliance: Protecting the expanding Medicaid program from fraud, waste, and abuse

The Office of Inspector General (OIG) issued its annual summary of the most significant management and performance challenges facing HHS. The annual summary is mandated by the Reports Consolidation Act of 2000 (P.L. 106-531) and is referred to as the Top Management Challenges (TMC). This year’s report included, as “Management Challenge 1,” the following goal: protecting an expanding Medicaid program from fraud, waste, and abuse.

As result of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), CMS reported adding 13.6 million beneficiaries, along with rapid expansion of costs. Coupled with the long-standing program integrity issues, the OIG noted that protecting the integrity of Medicaid has taken on heightened urgency with the rapid expansion of expenditures and beneficiaries and noted the following to support this position:

  • In light of 6.7 percent improper payment rate in Medicaid, updating eligibility systems to ensure appropriate eligibility determinations and applicable Federal Medical Assistance Percentage (FMAP) is imperative.
  • 75 percent of Medicaid beneficiaries nationwide are enrolled in Medicaid Managed Care. There is a history of program integrity concerns that states and plans are committing fraud for billing for services that were not provided, were medically unnecessary, or up-coded. CMS does not have the data necessary to identify and address possible fraud, waste, and abuse, or evidence that beneficiaries’ access to care may be impeded.
  • National Medicaid data is not complete, accurate, or timely, and additional data is needed to enhance national program integrity activities. CMS still faces challenges in its attempts to improve the availability and quality of Medicaid data. Limited implementation by states has hindered CMS’s Transformed Medicaid Statistical Information System (T- MSIS) initiative, which is key to CMS’ efforts to modernize and enhance the usefulness of state Medicaid data. Other attempts by CMS to improve data sharing between states have not been fully successful. OIG found that 12 percent of providers terminated for cause in one state Medicaid program were still participating in other states’ Medicaid programs.
  • States’ Medicaid policies result in the federal government paying a greater share of Medicaid costs than the FMAP percentages dictate.
  • Children enrolled in Medicaid do not receive all required preventive screenings; it has been identified that quality of care concerns exist regarding children’s treatment with antipsychotic drugs. Significant and persistent vulnerabilities continue that are related to Medicaid personal care services, which often includes ineffective program safeguards intended to ensure medical necessity, patient safety, and quality.

OIG recommendations for CMS

  • Continue developing a robust oversight for the Medicaid expansion and be vigilant in addressing program integrity risks associated with Medicaid expansion, including monitoring states’ compliance with eligibility requirements and FMAP expenditures.
  • Continue to work with states to ensure the submission of complete, accurate, and timely T- MSIS data.
  • Use its statutory enforcement mechanisms or seek legislative authority to employ alternative tools to compel state participation.
  • Continue to improve the data available for states to terminate providers terminated from another state Medicaid agency, the Children’s Health Insurance Program (CHIP), or Medicare by implementing a mandatory state reporting requirement of all for-cause provider terminations. Required reporting is a crucial part of creating a comprehensive data source and effective oversight.
  • Strengthen its oversight of state Medicaid waivers, including monitoring the costs of such waivers, and ensure that any oversight actions taken are publicly reported.
  • Continue to promote awareness of safe treatment and best practices for treating children with antipsychotic drugs and consider ways that states could implement periodic reviews of medical records of children who receive antipsychotic drugs.
  • Continue its efforts to improve delivery of preventive screenings for children, particularly on required reporting of vision and hearing screenings.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2015 Strategic Management Services, LLC. Published with permission.