“…Of the six payment risks GAO identified, state stakeholders responsible for ensuring Medicaid program integrity more often cited the following two as having a higher level of risk: (1) incorrect fee-for-service payments from MCOs, where the MCO paid providers for improper claims, such as claims for services not provided; and (2) inaccurate state payments to MCOs resulting from using data that are not accurate or including costs that should be excluded in setting payment rates.”
“We are making the following three recommendations to CMS: • The Administrator of CMS should expedite the planned efforts to communicate guidance, such as its compendium on Medicaid managed care program integrity, to state stakeholders related to Medicaid managed care program integrity. (Recommendation 1) • The Administrator of CMS should eliminate impediments to collaborative audits in managed care conducted by audit contractors and states, by ensuring that managed care audits are conducted regardless of which entity—the state or the managed care organization—recoups any identified overpayments. (Recommendation 2) • The Administrator of CMS should require states to report and document the amount of MCO overpayments to providers and how they are accounted for in capitation rate-setting. (Recommendation 3)…” Read the full report here.
Source: Report to Congressional Requesters – Medicaid Managed Care – Improvements Needed to Better Oversee Payment Risks – July 2018. GAO.
