Kusserow on Compliance: GAO calls for CMS to mitigate program risks in managed care

·       Medicaid enrollment in managed care rose in three years from 35 to 55 million beneficiaries

·       $170 billion Medicaid managed care is half of total federal Medicaid expenditures

·       CMS is not doing enough to ensure accuracy in payments

 

Congress called for the Government Accountability Office (GAO) to conduct a study of the Payment Error Rate Measurement (PERM), which  measures the accuracy of capitated payments for managed care, including CMS’s and states’ oversight. Driving this inquiry was the rapid growth of Medicaid managed care enrollment, which increased by 56 percent in three years, jumping from covering 35 million beneficiaries to 54.6 million beneficiaries. Federal Medicaid managed care expenditures last year were $171 billion, almost half of the total for Medicaid. The GAO focused on weaknesses in oversight, given the recent rapid growth. The GAO reviewed program integrity risks reported in 27 federal and state audits and investigations over a five year period; federal regulations and guidance on the PERM; and the CMS’s Focused Program Integrity Reviews. The GAO also contacted program integrity officials in the 16 states with a majority of 2016 Medicaid spending for managed care. The GAO found:

  1. Ten of 27 federal and state audits and investigations identified about $68 million in overpayments and unallowable MCO costs, not accounted for by PERM estimates.
  2. Another investigation resulted in a $137.5 million settlement.
  3. CMS does not have a process to track managed care overpayments and cannot determine whether states considered those overpayments when they set capitation rates.
  4. CMS is not doing enough to ensure that states are adequately paying managed Medicaid companies and that the plans are making correct payments to providers.
  5. The managed care component of the PERM neither includes a medical review of services delivered to enrollees, nor reviews of MCO records or data.
  6. CMS and states have updated regulations, focused reviews, and used federal program integrity contractors’ audits of managed care services, however, some of this is only recent, and it may not fully address risks across all states.
  7. CMS does not ensure identification and reporting of overpayments to providers and unallowable costs by MCOs.

The GAO called for CMS to consider and take steps to mitigate the program risks that are not measured in the PERM, such as overpayments and unallowable costs. Such an effort could include actions such as revising the PERM methodology or focusing additional audit resources on managed care. The GAO also recommended CMS expedite the release of planned guidance and requirements for states to report to the CMS overpayments made between managed-care providers and plans.

 

 

 

 

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 © 2017 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: OIG provides Medicaid fraud and overpayment update to Congress

The OIG testified before the Senate Committee on Homeland Security and Governmental Affairs regarding Medicaid Fraud and Overpayments. Up front, it was noted that the Medicaid program has 67 million beneficiaries, costing $600 billion annually with projected improper Medicaid payments at about $59 billion. Key points of the testimony were:

  1. Complete and reliable national Medicaid data—which is necessary for effective program oversight and to quickly detect and address improper payments, fraud, waste, or quality concerns—is limited.
  2. Transformed Medicaid Statistical Information System (T-MSIS) data was mandated to address problems with national Medicaid claims and eligibility data. All states except Wisconsin and the District of Columbia have begun reporting data to T‐MSIS, but the data elements may not mean the same thing across states. CMS must ensure that the same data elements are consistently reported and uniformly interpreted across states.
  3. Eighty percent of all Medicaid beneficiaries receive part or all of their services through managed care entities who are required to report medical claims data to states who then report it to CMS via T‐MSIS. Without accurate and timely data, it is not possible to analyze costs, utilization or trends; evaluate benefits; or determine the quality of services being provided.  Medicaid managed care encounter data was found to be incomplete and CMS needs to ensure this corrected.
  4.  Lack of quality national Medicaid data to identify fraud schemes and other vulnerabilities that cross state lines is hampering enforcement efforts. Identifying schemes in one state can alert other states to patterns of fraudulent or abusive practices that may be occurring in their jurisdiction and can be referred to law enforcement agencies. CMS must improve Medicaid data to ensure T‐MSIS achieves its full potential.
  5. States have not fully enacted enhanced provider screening that prevents bad actors from entering the Medicaid program to reduce improper payments and protect patients from harm, such as conducting fingerprint‐based criminal background checks and site visits. States need timely, complete, and accurate data to identify the providers seeking access to Medicaid monies and patients. CMS must ensure that states timely and fully implement critical safeguards.
  6. The Medicaid improper payment rate is 10.1 percent and CMS is working with state Medicaid agencies to develop corrective action plans that address state‐specific reasons for improper payments as a part of CMS’s Payment Error Rate Measurement Program (PERM). Additional guidance to the states by CMS is needed. OIG has also identified a number of states that inflate payment rates to increase their Federal Medicaid funding and CMS needs to closely review state Medicaid plans and plan amendments for potentially inappropriate cost‐shifting from states to the federal government.
  7. The OIG has found that states are not always correctly determining Medicaid eligibility for beneficiaries. The Affordable Care Act (ACA) allowed states to expand Medicaid eligibility and claim a higher Federal Medical Assistance Percentage, but incorrectly determining beneficiaries’ eligibility could result in the improper shift of costs from the state to the federal government. States must comply with requirements to verify applicants’ income, citizenship, identity, and other eligibility criteria in order to verify eligibility criteria.
  8. Medicaid is overpaying for prescription drugs due to underpaid rebates. Manufacturers are generally required to pay rebates to the states for covered outpatient drugs under the Medicaid Drug Rebate Program that includes reporting product and pricing information to CMS that is used to calculate the rebates owed. Manufacturer misreporting can result in manufacturers’ underpaying rebates, which inappropriately increases federal and state Medicaid costs. Overseeing states’ collection of manufacturer rebates remains a challenge for HHS.
  9. Medicaid must know with whom it is doing business, not only to prevent improper payments to ineligible providers, but also to protect beneficiaries from low‐quality care. The varying standards, and in some cases, minimal vetting, for Medicaid personal care services (PCS) providers, potentially expose the Medicaid program to financial fraud and Medicaid beneficiaries to abuse and neglect. CMS needs to improve states’ ability to monitor billing and care quality by enrolling PCS attendants as providers, or require them to register with their state Medicaid agencies, and assign each attendant a unique identifier.
  10. The OIG found that up to 99 percent of critical incidents of abuse and neglect of developmentally disabled were not reported to the appropriate law enforcement or state agencies as required. The OIG worked with the HHS Administration for Community Living, Office for Civil Rights, CMS, as well as with the DOJ and States to create a joint report entitled Ensuring Beneficiary Health and Safety in Group Homes Through State Implementation of Comprehensive Compliance Oversight. It features suggested model practices for states and CMS with four main aspects of handling critical incidents: investigation, reporting, correction, and transparency and accountability. It also detailed suggestions as to what actions states should take when group homes repeatedly fail to report incidents.
  11. The OIG partners with state Medicaid Fraud Control Units (MFCUs) which, last year, reported more than 1,500 convictions, nearly 1,000 civil settlements and judgments, and more than $1.8 billion in criminal and civil recoveries. The 50 existing MFCUs receive 75 percent of their funding on a matching basis from the federal government but often they encounter severe restrictions on their ability to maintain or expand staff.

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.

Connect with Richard Kusserow on Google+ or LinkedIn.

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Copyright © 2018 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: CMS releases Medicaid bulletin addressing opioid crisis

CMS has released an Informational Bulletin that provides states with information they can use when designing approaches to covering critical treatment services for Medicaid eligible infants with Neonatal Abstinence Syndrome (NAS), recognizing the serious problem of babies born with an addiction to drugs passed on from their mothers. CMS noted that Medicaid services can play a critical role in helping ensure access to treatment for these vulnerable infants who have Neonatal Abstinence Syndrome (NAS). Neonatal Abstinence Syndrome (NAS) is a postnatal drug withdrawal syndrome that occurs primarily among opioid-exposed infants shortly after birth. Experts consider NAS to be an expected and treatable result of women’s prenatal opioid or other substance use, although long term ramifications for the infants are still unknown. CMS noted an average of one infant born with NAS every 25 minutes in the United States and roughly 80 percent of infants treated for NAS receive their care through Medicaid. Appropriate treatment using the best evidence-based practices can help these infants withdraw from opioids and other substances and lead healthier lives. NAS treatment may occur not only in hospitals, but also in other settings.  In addition to Medicaid-covered treatment for infants, it is important for states to involve mothers and other caregivers in the infant’s care, as appropriate. The use of interventions like swaddling, quiet environments, little stimulation, skin-to-skin contact, and other environmental approaches are critical first-line care for these infants.

The CMS opioid technology guidance further advises states on which funding authorities may support health information technology efforts that could be used for the prevention and treatment of negative opioid outcomes. States may access enhanced federal funding to integrate innovative substance abuse treatment in areas facing provider shortages, particularly in rural areas, such as virtual treatment centers or remote counseling, into Medicaid care coordination technologies. They also describes how states can draw federal support for shared electronic care plans, which allows patients and providers to view and update a shared care plan describing goals for pain management regimens and counseling, and could complement Medication Assisted Therapy (MAT).

The letter describes how states might draw federal financing to support recommendations, such as integrating prescription drug monitoring systems data into EHRs and supporting interstate data sharing and electronic prescribing of controlled substances. In addition, the letter shows how states might use systems and funding to support advanced analytics for those looking to leverage data sources to create prediction models of patients at risk for opioid dependency and connect them with appropriate case management.

 

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.

Connect with Richard Kusserow on Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2018 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: OIG Attorneys continue cross-designation with DOJ

The HHS OIG issued its Semi-Annual Report for the first half of fiscal year (FY) 2018 (October-March) and summarizes key accomplishments, significant problems, abuses, deficiencies, and investigative outcomes relating to the administration of HHS programs and operations that were disclosed during the reporting period. Included in the report is a section referred to as the “Special Assistant U.S. Attorney Program.” Many are unaware of this program that unites under the DOJ attorneys and Special Agents of the OIG that are cross-designated as Special Assistant U.S. Attorneys. These OIG attorneys are detailed full time to the Fraud section of DOJ’s Criminal Division for temporary assignments, including assignments to the Health Care Fraud Strike Force. Other attorneys prosecute matters on a case-by-case basis. Both arrangements offer excellent litigation training for OIG attorneys and enhance collaboration between the departments in their efforts to fight fraud. Under this program, OIG attorneys have successfully litigated important criminal cases relating to the fraudulent billing of medical equipment and supplies, infusion therapy, and physical therapy, as well as other types of Medicare and Medicaid fraud.

In its report, the OIG cited as an example of how this program works in a Medicare fraud case in Texas where cross-designated Special Assistant U.S. Attorney prosecuted an individual for fraud. The individual owned and operated group homes in the Houston, Texas area and engaged in a scheme to defraud Medicare by receiving kickbacks in exchange for referring her group home residents for home health services. She pleaded guilty to making false statements to federal agents and was sentenced to 6 months in prison.

 

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.

Connect with Richard Kusserow on Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2018 Strategic Management Services, LLC. Published with permission.