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MEDICAID PROGRAM INTEGRITY: CMS Should Build on Current Oversight Efforts by Further Enhancing Collaboration with States
" Medicaid remains a high-risk program, partly due to concerns about improper payments. CMS oversees and supports states, in part, by reviewing their program integrity activities, hiring contractors to audit providers, and providing training. In recent years, CMS made changes to its Medicaid program integrity efforts, including a shift to collaborative audits. GAO was asked to examine CMS's oversight and support of states' Medicaid program integrity efforts. GAO examined, among other issues, (1) how CMS tailors its reviews to states' circumstances; (2) states' experiences with collaborative audits; and (3) CMS's steps to share promising program integrity practices. GAO reviewed CMS documents, including state program integrity reports, and data on collaborative audits. GAO interviewed officials from CMS and eight states selected based on expenditures, managed care use, and number of collaborative audits, among other factors. "
"Testimony The Centers for Medicare & Medicaid Services (CMS), the federal agency that oversees Medicaid, estimated that improper payments in the federal-state Medicaid program were $21.9 billion in fiscal year 2011. The Deficit Reduction Act of 2005 established the Medicaid Integrity Program and gave CMS an expanded role in assisting and improving the effectiveness of state activities to ensure proper payments. Making effective use of this expanded role, however, requires that federal resources are targeted appropriately and do not duplicate state activities. GAO was asked to testify on Medicaid program integrity. GAO's statement focuses on how CMS's expanded role in ensuring Medicaid program integrity (1) poses a challenge because of overlapping state and federal activities regarding provider audits and (2) presents opportunities through oversight to enhance state program integrity efforts. To do this work, GAO reviewed CMS reports and documents on Medicaid program integrity as well as its own and others' reports on this topic. In particular, GAO reviewed CMS reports that documented the results of its state oversight and monitoring activities. GAO also interviewed CMS officials in the agency's Medicaid Integrity Group (MIG), which was established to implement the Medicaid Integrity Program. This work was conducted in November and December 2011. GAO discussed the facts in this statement with CMS officials. What GAO Found The key challenge faced by the Medicaid Integrity Group (MIG) is the need to avoid duplication of federal and state program integrity efforts, particularly in the area of auditing provider claims. In 2011, the MIG reported that it was redesigning its national provider audit program. Previously, its audit contractors were using incomplete claims data to identify overpayments. According to MIG data, overpayments identified by its audit contractors since fiscal year 2009 were not commensurate with its contractors' costs. The MIG's redesign will result ..."
" In 2011, CMS estimated that Medicaid and Medicare had improper payments of $21.9 billion and almost $43 billion, respectively-among the largest for all federal programs. Both health care programs are on GAO's list of high-risk programs. Over the years, Congress has passed legislation designed to help address program integrity issues in the two programs but they remain vulnerable to fraud, waste, and abuse. The program integrity challenges are different for Medicaid and Medicare. With 51 distinct state-based programs, Medicaid has complex challenges for finding the appropriate balance between state and federal efforts. Medicare uses contractors to help administer the program and CMS must oversee their efforts. This statement examines the progress made and important steps still to be taken in these programs. GAO focused on four key strategies and recommendations that were designed to facilitate them that were identified in prior work and that could help reduce improper payments: (1) strengthening provider enrollment standards and procedures to ensure that only legitimate providers participate in the program; (2) improving prepayment controls; (3) improving postpayment claims review and recovery of improper payments; and (4) developing a robust process for addressing identified vulnerabilities. This statement is based on GAO products issued from April 2004 through May 2012 and interviews with agency officials and other stakeholders. In May 2012, GAO"
In fiscal year 2013, the Medicaid program covered about 71.7 million individuals at a cost of $431.1 billion, of which CMS estimated that $14.4 billion (5.8 percent) were improper payments. Multiple state and federal entities are involved in program integrity efforts, such as payment review, auditing, and investigating fraud. GAO was asked to examine how these entities ensure comprehensive Medicaid program integrity. This report examines state and federal roles and responsibilities to identify potential (1) gaps in efforts to ensure Medicaid program integrity coverage; and (2) fragmentation, overlap, or duplication of program integrity efforts, and efforts to coordinate activities. GAO examined relevant federal laws and regulations, CMS guidance, and state program integrity reviews. GAO also interviewed officials from CMS and HHS's Office of Inspector General, as well as PI unit and MFCU officials from seven states.
" Medicaid has the second-highest estimated improper payments of any federal program that reports such data. The Deficit Reduction Act of 2005 created the Medicaid Integrity Program to oversee and support state program integrity activities. CMS, the federal agency within HHS that oversees Medicaid, established the MIG to implement this new program. This report assesses (1) the MIG's use of two types of contractors to review and audit state Medicaid claims, (2) the MIG's implementation of other oversight and support activities, and (3) CMS and state reporting on the results of their program integrity activities. GAO analyzed MIG data on its contractors' audits, training program for state officials, comprehensive state reviews, and state assessments; analyzed reports that summarized the monetary returns from MIG and state program integrity activities; and interviewed MIG officials, contractors, and state program integrity officials. "
Medicaid is a significant expenditure for the federal government and the states, with total federal outlays of $310 billion in fiscal year 2014. CMS reported an estimated $17.5 billion in potentially improper payments for the Medicaid program in 2014. GAO was asked to review beneficiary and provider enrollment-integrity efforts at selected states. This report (1) identifies and analyzes indicators of improper or potentially fraudulent payments in fiscal year 2011, and (2) examines the extent to which federal and state oversight policies, controls, and processes are in place to prevent and detect fraud and abuse in determining eligibility. GAO analyzed Medicaid claims paid in fiscal year 2011, the most-recent reliable data available, for four states: Arizona, Florida, Michigan, and New Jersey. These states were chosen because they were among those with the highest Medicaid enrollment; the results are not generalizable to all states. GAO performed data matching with various databases to identify indicators of potential fraud, reviewed CMS and state Medicaid program-integrity policies, and interviewed CMS and state officials performing oversight functions.
Medicaid is a joint federal-state program that provides health care coverage to certain low-income individuals. The program is overseen by CMS, while the states that administer Medicaid are tasked with taking actions to ensure its integrity. Such actions include implementing IT systems that provide program integrity analysts with capabilities to assess claims, provider, beneficiary, and other data relevant to Medicaid; and supporting efforts to prevent and detect improper payments to providers. GAO was asked to review states' implementation of IT systems that support Medicaid. GAO determined (1) the types and implementation status of the systems used by states to support program integrity initiatives; (2) the extent to which CMS is making available data, technical resources, and funds to support Medicaid programs' efforts to implement systems, and the effectiveness of the states' systems; and (3) key challenges that Medicaid programs have faced in using IT to enhance program integrity initiatives, and CMS's actions to support efforts to overcome them. To do this, GAO analyzed information from 10 selected states covering a range of expenditures on such systems, reviewed program management documentation, and interviewed CMS officials.