Improper spending in Medicaid is on the rise. In fiscal year 2017, the Medicaid program doled about $37 billion in improper payments, an increase from $29.1 billion in improper payments recorded in 2015, according to a report from the Government Accountability Office.
In total, the federal-state program spent about $596 billion last year. CMS has taken steps to limit improper payments, but there is more the agency could do, according to GAO, including improving data quality, oversight and federal-state collaboration.
A lack of complete, accurate and timely data is a “fundamental challenge” to the oversight of the program, which is also large in scale and diversity, making it difficult to manage, according to GAO.
“This challenge has hindered CMS’s ability to ensure the appropriate use of federal and state dollars for beneficiary care,” the report reads. “Without reliable data, CMS is unable to effectively monitor who is providing services, or the type of services provided.”
GAO also recently found similar problems with managed Medicaid plans, with numerous oversight challenges impacting the ability of CMS to ensure proper payments.
GAO made a few recommendations to CMS, including improving the completeness and comparability of the data from CMS’s new statistical information system as well as recommendations to improve oversight. GAO suggest CMS improve oversight by managing program risks and ensuring beneficiaries have access to healthcare services.
CMS relies on data to oversee Medicaid, but several issues make state-reported data less useful. For example, in 2015, CMS did not collect accurate data on Medicaid enrollment by eligibility type in its set, and therefore couldn’t identify improper expenditures from incorrect eligibility determinations, GAO found. In addition, utilization data has been shown to be incomplete and reported late by states.
CMS is already addressing the issue as it develops a reliable national repository for Medicaid data, the Transformed Medicaid Statistical Information System (T-MSIS), which will collect more information on enrollees than prior systems.
Among its recommendations, GAO also urged CMS to improve federal-state collaboration. The Medicaid program expanded under the Affordable Care Act and in the years since its passage, yet communication issues between CMS contractors and state officials have become barriers when it comes to identifying substantial overpayments to providers. Under Medicaid, states are responsible for administering the day-to-day operations of the programs, while CMS provides oversight and technical assistance, with federal oversight ensuring the design and operation of the state programs meet federal requirements and payments are made properly.
See the full report here.
Amy joined TriMed Media as a Senior Writer for HealthExec after covering home care for three years. When not writing about all things healthcare, she fulfills her lifelong dream of becoming a pirate by sailing in regattas and enjoying rum. Fun fact: she sailed 333 miles across Lake Michigan in the Chicago Yacht Club "Race to Mackinac."