Medicaid Program Integrity and Current Issues
Summary
Robin Rudowitz, Rachel Garfield, and Elizabeth Hinton, “10 Things to Know about Medicaid: Setting the Facts Straight”, Kaiser Family Foundation, March 6, 2019, https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-medicaid-setting-the-facts-straight/
Centers for Medicare & Medicaid Services, 2019 Estimated Improper Payment Rates for Centers for Medicare & Medicaid Services (CMS) Programs (November 18, 2019), https://www.cms.gov/newsroom/press-releases/fiscal-year-fy-2019-medicare-fee-service-improper-payment-rate-lowest-2010-while-data-points and Department of Health and Human Services, FY 2019 Agency Fiscal Report, https://www.hhs.gov/sites/default/files/fy2019-hhs-agency-financial-report-final.pdf
Centers for Medicare and Medicaid Services, CMS Administrator Seema Verma’s Speech to the National Association of Medicaid Directors in Washington, D.C. (November 12, 2019), https://www.cms.gov/newsroom/press-releases/cms-administrator-seema-vermas-speech-national-association-medicaid-directors-washington-dc and Centers for Medicare and Medicaid Services, Oversight of State Medicaid Claiming and Program Integrity Expectations (June 20, 2019), https://www.medicaid.gov/federal-policy-guidance/downloads/cib062019.pdf
Department of Health and Human Services, FY 2019 Agency Fiscal Report, https://www.hhs.gov/sites/default/files/fy2019-hhs-agency-financial-report-final.pdf
Issue Brief
“Program Integrity,” MACPAC, accessed November 26, 2019, https://www.macpac.gov/subtopic/program-integrity/
Victoria Wachino, “The New Medicaid Integrity Program: Issues and Challenges in Ensuring Program Integrity in Medicaid”, Kaiser Family Foundation, June 2007, https://www.kff.org/wp-content/uploads/2013/01/7650.pdf
Ibid.
Four priorities highlighted by Angela Brice-Smith of Centers for Medicare & Medicaid, Medicaid Integrity Group in her address to MACPAC, entitled, Addressing Medicaid Program Integrity. November 2011.
Peter Budetti, “Fighting Fraud and Waste in Medicare and Medicaid” statement before Senate Committee on Appropriations, Subcommittee on Labor, Health and Human Services, Education and Related. February 15, 2011. Accessed May 21, 2012. Available at: https://www.govinfo.gov/content/pkg/CHRG-112shrg64653/html/CHRG-112shrg64653.htm
“Patient Protection and Affordable Care Act, (Public Law 111-148 Title VI – Transparency and Program Integrity, 23 March 2010). Available at: http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf
Center for Medicare and Medicaid Services, The Health Care Fraud and Abuse Control Program Protects Consumers and Taxpayers by Combating Health Care Fraud (February 26, 2016), https://www.cms.gov/newsroom/fact-sheets/health-care-fraud-and-abuse-control-program-protects-consumers-and-taxpayers-combating-health-care
United States Government Accountability Office, CMS Oversight Should Ensure State Implementation of Screening and Enrollment Requirements (October 10, 2019), https://www.gao.gov/products/GAO-20-8 and “21st Century Cures Act” (Public Law 114-255, 13 December 2016). Available at: https://www.gpo.gov/fdsys/pkg/PLAW-114publ255/pdf/PLAW-114publ255.pdf
United States Government Accountability Office, Actions Needed to Mitigate Billions in Improper Payments and Program Integrity Risks (June 27, 2018), https://www.gao.gov/assets/700/692821.pdf
The Improper Payments Information Act (IPIA) of 2002 (amended in 2010 by the Improper Payments Elimination and Recovery Act or IPERA) requires the heads of federal agencies to annually review programs they administer and identify those that may be susceptible to significant improper payments, to estimate the amount of improper payments, to submit those estimates to Congress, and to submit a report on actions the agency is taking to reduce the improper payments. The Office of Management and Budget (OMB) has identified Medicaid and CHIP as programs at risk for significant improper payments. As a result, CMS developed the PERM program to comply with the IPIA and related guidance issued by OMB.
Centers for Medicare & Medicaid Services, 2019 Estimated Improper Payment Rates for Centers for Medicare & Medicaid Services (CMS) Programs (November 18, 2019), https://www.cms.gov/newsroom/fact-sheets/2019-estimated-improper-payment-rates-centers-medicare-medicaid-services-cms-programs
Ibid.
Department of Health and Human Services, FY 2019 Agency Fiscal Report, https://www.hhs.gov/sites/default/files/fy2019-hhs-agency-financial-report-final.pdf
United States Government Accountability Office, Actions Needed to Mitigate Billions in Improper Payments and Program Integrity Risks (June 27, 2018), https://www.gao.gov/assets/700/692821.pdf
Ibid.
Ibid.
Ibid.
U.S. Department of Health and Human Services Office of Inspector General, California Made Medicaid Payments on Behalf of Newly Eligible Beneficiaries Who Did Not Meet Federal and State Requirements (February 20, 2018), https://oig.hhs.gov/oas/reports/region9/91602023.asp; Office of Inspector General, New York Did Not Correctly Determine Medicaid Eligibility for Some Newly Enrolled Beneficiaries (January 5, 2018), https://oig.hhs.gov/oas/reports/region2/21501015.asp; Office of Inspector General, Kentucky Did Not Always Perform Medicaid Eligibility Determinations for Non-Newly Eligible Beneficiaries in Accordance With Federal and State Requirements (August 17, 2017), https://oig.hhs.gov/oas/reports/region4/41608047.asp; and, Centers for Medicare and Medicaid Services, Medicaid Program Integrity: A Shared and Urgent Responsibility (June 25, 2019), https://www.cms.gov/blog/medicaid-program-integrity-shared-and-urgent-responsibility
Centers for Medicare and Medicaid Services, CMS Medicaid Program Integrity Strategy (June 26, 2018), https://www.medicaid.gov/state-resource-center/downloads/program-integrity-strategy-factsheet.pdf
Ibid.
Ibid.
Ibid.
Ibid.
Ibid.
Ibid.
Centers for Medicare and Medicaid Services, Oversight of State Medicaid Claiming and Program Integrity Expectations (June 20, 2019), https://www.medicaid.gov/federal-policy-guidance/downloads/cib062019.pdf and Centers for Medicare and Medicaid Services, CMS Administrator Seema Verma’s Speech to the National Association of Medicaid Directors in Washington, D.C., November 12, 2019, https://www.cms.gov/newsroom/press-releases/cms-administrator-seema-vermas-speech-national-association-medicaid-directors-washington-dc
Centers for Medicare and Medicaid Services, CMS Medicaid Program Integrity Strategy (June 26, 2018), https://www.medicaid.gov/state-resource-center/downloads/program-integrity-strategy-factsheet.pdf
Department of Health and Human Services, FY 2019 Agency Fiscal Report, https://www.hhs.gov/sites/default/files/fy2019-hhs-agency-financial-report-final.pdf
Ibid.
United States Government Accountability Office, Actions Needed to Mitigate Billions in Improper Payments and Program Integrity Risks (June 27, 2018), https://www.gao.gov/assets/700/692821.pdf
The Department of Health and Human Services And The Department of Justice, Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2018 (May 2019), https://www.oig.hhs.gov/publications/docs/hcfac/FY2018-hcfac.pdf
Appendix A
“Medicaid Integrity Program – General Information”, Centers for Medicare & Medicaid Services, accessed December 12, 2019, https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/MedicaidIntegrityProgram/index?redirect=/MedicaidIntegrityProgram/ and Medicaid and CHIP Payment and Access Commission, March 2012 Report to the Congress on Medicaid and CHIP (March 2012), https://www.macpac.gov/publication/report-to-the-congress-on-medicaid-and-chip-312/
U.S. Department of Health and Human Services Office of Inspector General, Use of Funds Appropriated to the Office of Inspector General for Medicaid-Related Program Integrity Activities (March 2009), http://oig.hhs.gov/publications/medicaid_integrity/files/medicaid_integrity_reportFY08.pdf and “Enforcement Actions”, U.S. Department of Health and Human Services Office of Inspector General, accessed December 2, 2019, https://oig.hhs.gov/fraud/enforcement/index.asp
“Medicaid Integrity Program – General Information”, Centers for Medicare & Medicaid Services, accessed December 12, 2019, https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/MedicaidIntegrityProgram/index?redirect=/MedicaidIntegrityProgram/
Medicaid and CHIP Payment and Access Commission, March 2012 Report to the Congress on Medicaid and CHIP (March 2012), https://www.macpac.gov/publication/report-to-the-congress-on-medicaid-and-chip-312/
“Medicaid Fraud Control Units”, National Association of Medicaid Fraud Control Units, accessed December 2, 2019, https://www.namfcu.net/mfcu-information.php