ENFORCEMENT

CMS Takes 3 New Measures to Bolster Medicaid Program Integrity

With Medicaid spending on the rapid ascent, CMS unveiled a trio of new initiatives to bolster program integrity and make states more accountable for compliance with federal rules.

1. MLR Audits
CMS will step up audits of state claims for federal match funds and medical loss ratios (MLRs). These MLR audits will examine how much a particular state spent on clinical services and quality improvement versus how much it spent on administration and took in profits. The audits will also review states’ rate setting methods.

2. State Beneficiary Eligibility Audits
CMS will also conduct new audits of state beneficiary eligibility determinations focusing on states previously found by the OIG to be high risk. Specifically, the agency will examine how the state determines which groups are eligible for Medicaid and whether it did any jiggering of its eligibility criteria in response to recent Medicaid expansions and federal match rate increases.

3. Optimization Claims & Provider Data Provided by States
Last but not least, CMS will utilize advanced analytics and other innovative solutions to improve Medicaid eligibility and payment data. Over the coming months, the agency will validate the quality and completeness of the enhanced data the states are now submitting with an eye to leveraging the data to achieve Medicaid program integrity objectives.

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