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CMS Announces Medicaid Program Integrity Initiatives

June 29, 2018

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PRESS CONTACTS
Mary Mullaney, Director, Hospital Payment Policies
Andrew Amari, Hospital Policy and Regulatory Specialist

The Centers for Medicare and Medicaid Services (CMS) June 26 announced three new initiatives in its efforts to strengthen Medicaid program integrity. Medicaid spending has increased over $100 billion from 2013 to 2016, and the federal share increased by roughly $100 billion, spawning CMS’s reconsideration of its current integrity efforts. CMS notes that it seeks to strengthen integrity through transparency, accountability, and innovative analytics.

Specifically, CMS has three new initiatives in furtherance of its integrity efforts. First, it seeks to emphasize program integrity in audits of state claims for federal match funds and medical loss ratios (MLRs). CMS plans to begin auditing some states based on the difference between amount spent on clinical services and quality and the amount spent on administration and profit.

Second, CMS plans to conduct new audits of state beneficiary determinations. States deemed “high risk” by the Department of Health and Human Services (HHS) Office of Inspector General (OIG) will be audited to look at how they determine eligibility, as well as how Medicaid expansion has affected those eligibility policies. In 2022 CMS may issue disallowances to states based on Payment Error Rate Measurement (PERM) program findings.

Finally, CMS seeks to use advanced analytics to improve Medicaid eligibility and payment data. In this endeavor, CMS claims it will partner with states to ensure Medicaid data are complete and accurate. To ensure this is the case, CMS says it will validate the quality and completeness of the data.

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